Jeffrey Ponsky

677 statements · 11 topics · summaries given as host listed separately

Colorectal / ARM & Hirschsprung · episode host Inguinal Hernia · episode host Low Cardiac Output · episode host Sarcoma (Ewing/Rhabdo) · episode host Soft Tissue Sarcoma (lymph nodes) · episode host

Featured statements

▶ Ep 1 · 13:02
Easy gallbladders are the ones where you can make the bad mistakes. There can be accessory cystic ducts, there can be problems with the cystic artery that you didn't realize, an anterior and posterior one, and you have to be careful. So it's real easy, make yourself slow down. You know you're going to go slow on a hard one. Go slow on an easy one.
quote · Acute Cholecystitis
▶ Ep 7 · 6:15
we have to do a major laparotomy on these babies, uh, but we have an idea for performing this, uh, by a new technique. Uh, we don't have any idea if it'll work. We think it will, it's pretty simple, but if it doesn't, we will do the laparotomy right there and then and complete the gastrostomy
quote · Foundations of Minimally Invasive & Endoscopic Surgery
▶ Ep 1 · 24:40
The rule is, in the old days, everybody got ERCP the day they came in. Hydrate them, make them NPO, watch them in the hospital, and don't get the ERCP on the first day because when we did that, we found that two-thirds of the patients that we did the ERCPs on had normal ERCPs.
quote · Acute Cholecystitis
▶ Ep 11 · 44:37
A primary end-to-end repair of the common bile duct is almost always fraught with failure. Most often, a common duct injury, unless it's just a lateral injury, is best treated with a hepatic oj genostomy.
quote · Pancreatitis
▶ Ep 5 · 50:45
The endoscope is now. The vehicle, it's the car that gets us to our destination. It drives us to our destination, then we put it down, we have it fixed, and we start to operate endoscopically
quote · Foundations of Minimally Invasive & Endoscopic Surgery
▶ Ep 2 · 51:38
There's no reason that you can't be empathetic and be interested in psychiatric disease and still be somebody interested in the technical sides.
quote · Psychomotor Retardation

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Jeffrey's statements about Acute Cholecystitis 53 statements

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Gallstone Disease

▶ Ep 1 · 1:53
clinical Biliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative. ↗
▶ Ep 1 · 5:00
clinical Modern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks. ↗
▶ Ep 1 · 5:40
clinical For stable acute cholecystitis without peritonitis, it is reasonable to wait until the next operating day (e.g., Monday if presenting Saturday) rather than operating emergently. ↗
▶ Ep 1 · 6:10
clinical There is no evidence that prophylactic antibiotics help in acute cholecystitis management. ↗
▶ Ep 1 · 12:12
clinical The sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas. ↗
▶ Ep 1 · 12:40
clinical After isolating the cystic duct-gallbladder junction, turning the hook cautery toward the gallbladder and lifting while cauterizing gains an additional half-centimeter of cystic duct length. ↗
▶ Ep 1 · 13:02
quote Easy gallbladders are the ones where you can make the bad mistakes. There can be accessory cystic ducts, there can be problems with the cystic artery that you didn't realize, an anterior and posterior one, and you have to be careful. So it's real easy, make yourself slow down. You know you're going to go slow on a hard one. Go slow on an easy one. ↗
▶ Ep 1 · 13:02
opinion Easy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed. ↗
▶ Ep 1 · 14:50
clinical Routine intraoperative cholangiography is debated; some institutions do it in every case for teaching and to improve transcystic exploration skills, while selective use based on risk factors (pancreatitis history, jaundice, dilated duct) is also acceptable. ↗
▶ Ep 1 · 18:33
clinical When contrast on cholangiogram flows only distally into the duodenum, pressing on the papilla with the laparoscope under fluoroscopy forces contrast proximally, avoiding the need for morphine to induce sphincter spasm (technique taught by Michelle Gagné). ↗
▶ Ep 1 · 19:00
clinical Intraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy. ↗
▶ Ep 1 · 20:30
quote If you have a patient that you did a lap choleon, and they call you because they're having pain, something's wrong. Lap choleys don't have pain if everything went well. Now, I may be wrong in 1% of cases, but not many. The patient calls you, the mother calls you, or anybody calls you, says, you know, he's a little nausea, he's not eating well, a little bloated, and he's having pain. It's three days later. Come into the emergency room. Stat. Because in my mind, that's a bile leak, and even, God forbid, a common duct injury until proven otherwise. ↗
▶ Ep 1 · 20:30
clinical Any patient with pain 3-5 days after laparoscopic cholecystectomy should be assumed to have a bile leak or bile duct injury until proven otherwise; laparoscopic cholecystectomies do not cause pain if everything went well. ↗
▶ Ep 1 · 21:11
clinical For suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP. ↗
▶ Ep 1 · 21:32
opinion HIDA scans are useful to confirm normal biliary drainage when postoperative pain occurs without fluid collection, but are less useful than CT for detecting bile leaks. ↗
▶ Ep 1 · 22:37
clinical For bile leaks (typically cystic duct), ERCP with sphincterotomy and short stent (10 French, 5cm) decompresses the biliary system and stops drainage; stent is removed at 3-6 weeks. ↗
▶ Ep 1 · 23:41
clinical Biliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative. ↗
▶ Ep 1 · 24:11
clinical Gallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla. ↗
▶ Ep 1 · 24:40
quote The rule is, in the old days, everybody got ERCP the day they came in. Hydrate them, make them NPO, watch them in the hospital, and don't get the ERCP on the first day because when we did that, we found that two-thirds of the patients that we did the ERCPs on had normal ERCPs. ↗
▶ Ep 1 · 24:40
clinical In the old practice, all patients with gallstone pancreatitis received ERCP on presentation, but two-thirds had normal ERCPs because the stone had already passed. ↗
▶ Ep 1 · 25:10
clinical Current management of gallstone pancreatitis: admit, hydrate, NPO, observe overnight and check amylase/lipase trend. If improving, proceed to cholecystectomy during that admission. If worsening or jaundice persists, perform ERCP with sphincterotomy. ↗
▶ Ep 1 · 26:27
opinion The choice between preoperative ERCP versus intraoperative common duct exploration depends on local resources, surgeon comfort with laparoscopic ductal techniques, and availability of fluoroscopy and choledocoscopy. ↗
▶ Ep 1 · 30:14
clinical For intraoperative common duct stone clearance, after cholangiogram shows a stone (meniscus sign), give 1 amp (1mg) glucagon IV, wait 1-2 minutes, flush with saline, and repeat cholangiogram. ↗
▶ Ep 1 · 30:56
clinical If glucagon fails to clear the stone, pass a soft-tip wire through the cystic duct under fluoroscopy into the duodenum to attempt to dislodge it; never push against resistance. ↗
▶ Ep 1 · 31:35
clinical A Dormia basket can be passed closed into the duodenum under fluoroscopy, opened slightly, and pulled back with jiggling to catch stones; alternatively, a #5 Fogarty catheter (vascular Fogarty works) can be inflated in the duodenum, pulled to the papilla, deflated slightly, re-inflated and pulled back. ↗
▶ Ep 1 · 32:44
clinical Modern choledocoscopes are less than 3mm diameter and can be passed through the cystic duct (sometimes requiring balloon dilation) for direct stone visualization and extraction with Dormia basket or balloon. ↗
▶ Ep 1 · 33:27
clinical After transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties. ↗
▶ Ep 1 · 34:56
clinical Laparoscopic common bile duct exploration via choledocotomy should only be performed in dilated ducts (>1-1.5cm, ideally 2cm) to avoid stricture risk; small-caliber ducts with stones should be managed with ERCP. ↗
▶ Ep 1 · 35:30
clinical For laparoscopic choledocotomy, do not divide the cystic duct—use the gallbladder for lateral retraction while dissecting down to expose the anterior common duct surface. ↗
▶ Ep 1 · 37:40
clinical T-tube preparation for choledocotomy closure: cut to 1 inch on each side of the T, bevel the edges, remove half the back wall to facilitate insertion and later removal. ↗
▶ Ep 1 · 38:50
clinical T-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks. ↗
▶ Ep 1 · 39:27
clinical For severe pancreatitis with large phlegmon in the pancreatic head, obtain CT and consider waiting 6 weeks before cholecystectomy to allow inflammation to resolve. ↗
▶ Ep 1 · 40:00
clinical For patients with multiple stones extending up both hepatic ducts in a very dilated common duct, or stone-formers like sickle cell patients, consider choledochoduodenostomy (2cm anastomosis) as a drainage procedure to allow future stones to pass. ↗
▶ Ep 1 · 41:04
clinical Percutaneous cholecystostomy can temporize severe acute cholecystitis in high-risk patients or those with large phlegmon, allowing interval cholecystectomy at 6 weeks, but requires normal clotting studies. ↗
▶ Ep 1 · 41:47
clinical In cases where anatomy is unrecognizable intraoperatively, subtotal cholecystectomy is acceptable: remove the anterior wall or fundus, cauterize the remaining mucosa on the back wall with bovie to prevent mucocele, place drains, and accept a controlled leak. ↗
▶ Ep 1 · 42:29
clinical Common bile duct injuries typically occur during 'easy' cases when surgeons become complacent and fail to maintain vigilance. ↗
▶ Ep 1 · 43:00
clinical The common duct can come up to the gallbladder and take a bend like a knee, appearing identical to the cystic duct; only continued dissection reveals the true 2-3mm cystic duct coming off the 'knee.' ↗
▶ Ep 1 · 43:29
clinical Being able to pass an instrument around a structure does not prove it is the cystic duct—the common bile duct can be encircled and mistakenly used for retraction. ↗
▶ Ep 1 · 44:00
clinical If common bile duct injury is recognized intraoperatively: STOP immediately, call for help, and assess. If shaken or inexperienced with hepaticojejunostomy, do not attempt repair. ↗
▶ Ep 1 · 44:00
quote If you're going to do biliary surgery, this could happen to anyone. Know that. It's not an incrimination of you. Stop. Suck it out. Take a few breaths and if you have another partner, call them in. ↗
▶ Ep 1 · 44:20
quote What happens in most of these cases is the primary injury is compounded by the attempted repair. ↗
▶ Ep 1 · 44:20
clinical In most bile duct injury cases, the primary injury is compounded by the attempted repair. ↗
▶ Ep 1 · 44:37
clinical Primary end-to-end repair of transected common bile duct is almost always fraught with failure; most common duct injuries (except small lateral injuries) are best treated with hepaticojejunostomy. ↗
▶ Ep 1 · 44:37
quote A primary end-to-end repair of the common bile duct is almost always fraught with failure. Most often, a common duct injury, unless it's just a lateral injury, is best treated with a hepatic oj genostomy. ↗
▶ Ep 1 · 44:56
clinical For small lateral common duct injuries, place a small T-tube rather than primary suture closure, as suture alone will leak. ↗
▶ Ep 1 · 45:37
clinical For complete common duct transection, leave everything alone, place multiple drains, do not place ties or tubes that will compromise remaining duct length for the hepatobiliary surgeon, and transfer the patient. ↗

Acute Cholecystitis

▶ Ep 2 · 27:51
clinical Ponsky's bailout technique for horrible cases: open the gallbladder, remove all stones, place a large cholecystostomy tube, leaving an empty gallbladder with drainage. ↗

Acute Cholecystitis

▶ Ep 6 · 18:31
quote That's how the attending steals the case from the resident here with the sucker. ↗
▶ Ep 6 · 20:19
clinical Taking the posterior gallbladder wall off the liver bed just superior to the cystic duct-gallbladder junction provides increased length for safer dissection. ↗
▶ Ep 6 · 28:14
clinical A bailout technique for severe cases is to open the gallbladder, remove all stones, place a large cholecystostomy tube, creating an empty gallbladder with drainage. ↗

Acute Cholecystitis

▶ Ep 7 · 4:21
clinical Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed (usually by a stone), causing backup of pressure in the gallbladder with decreased blood flow in the wall, and the wall can eventually rupture. ↗
▶ Ep 7 · 20:18
clinical Taking some of the gallbladder just superior to the cystic duct junction and removing the back wall off the liver bed gives increased length for dissection. ↗
▶ Ep 7 · 27:07
opinion There is no fear of adding another trocar—they are free and there is nothing magical about one number or another; just put them where you need them. ↗
Jeffrey's statements about Choledocholithiasis 4 statements

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Acute Cholecystitis

▶ Ep 1 · 27:51
clinical Ponsky's bailout technique for horrible cases: open the gallbladder, remove all stones, place a large cholecystostomy tube, leaving an empty gallbladder with drainage. ↗

Acute Cholecystitis

▶ Ep 7 · 18:31
quote That's how the attending steals the case from the resident here with the sucker. ↗
▶ Ep 7 · 20:19
clinical Taking the posterior gallbladder wall off the liver bed just superior to the cystic duct-gallbladder junction provides increased length for safer dissection. ↗
▶ Ep 7 · 28:14
clinical A bailout technique for severe cases is to open the gallbladder, remove all stones, place a large cholecystostomy tube, creating an empty gallbladder with drainage. ↗
Jeffrey's statements about Cholelithiasis 3 statements

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Acute Cholecystitis

▶ Ep 7 · 4:21
clinical Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed (usually by a stone), causing backup of pressure in the gallbladder with decreased blood flow in the wall, and the wall can eventually rupture. ↗
▶ Ep 7 · 20:18
clinical Taking some of the gallbladder just superior to the cystic duct junction and removing the back wall off the liver bed gives increased length for dissection. ↗
▶ Ep 7 · 27:07
opinion There is no fear of adding another trocar—they are free and there is nothing magical about one number or another; just put them where you need them. ↗
Jeffrey's statements about Foundations of Minimally Invasive & Endoscopic Surgery 234 statements

Open the Foundations of Minimally Invasive & Endoscopic Surgery collection →

SAGES Stories Episode 11 – Jeff Ponsky, MD

▶ Ep 3 · 6:49
clinical Ponsky had a 2.027 GPA graduating from Cleveland Heights High School and his college counselor recommended trade school instead of college. ↗
▶ Ep 3 · 9:01
quote Look, I'm gonna do this as best I can do. I don't know what I'm gonna do. All I know is that I'm gonna work my butt off, and I'm not gonna screw around and I'm not gonna party cause I've done that my whole life and now I was just gonna study. ↗
▶ Ep 3 · 9:17
opinion Ponsky's transformation in college came from memorizing everything and studying constantly, discovering he had an exceptional memory that allowed him to 'eat the book and spit it out.' ↗
▶ Ep 3 · 21:12
clinical Walter Pore taught pinch grafting technique at Metro Hospital, where students would inject local anesthesia, harvest small 'postage stamp' skin grafts from the thigh, and apply them to debrided bedsores. Pore emphasized giving patients zinc supplementation. ↗
▶ Ep 3 · 25:21
clinical Gastroenterologists at University Hospitals refused to train surgeons in endoscopy, telling Ponsky 'we're not training any surgeons.' ↗
▶ Ep 3 · 25:47
clinical Ponsky trained in endoscopy with Jim King in Canton, Ohio, performing approximately 500 cases over 5-6 months during an extended elective. ↗
▶ Ep 3 · 26:57
clinical Early endoscopes were cleaned with green soap and stored in the back of cars, without high-level disinfection protocols. Operators did not wear gloves during procedures. ↗
▶ Ep 3 · 28:30
clinical When SAGES started, it had approximately 300 members. When Ponsky became president in 1990, the society was giving courses on surgical endoscopy and its relationship to surgical problem-solving. ↗
▶ Ep 3 · 28:48
clinical Jacques Perissat showed the video of laparoscopic cholecystectomy in the exhibit hall at the SAGES meeting in Louisville, Kentucky, marking a pivotal moment when Ponsky was SAGES president. ↗
▶ Ep 3 · 29:04
clinical When laparoscopic cholecystectomy was introduced, instruments could not be purchased and surgeons had to use gynecologic instruments initially. ↗
▶ Ep 3 · 29:10
clinical Ponsky took one of the first laparoscopic cholecystectomy courses taught by Nat Soper, George Bercy, John Hunter, and John Sackier in Salt Lake City. ↗
▶ Ep 3 · 29:27
clinical Ponsky's first two laparoscopic cholecystectomies at Mount Sinai were proctored by David Dupper, who had performed only 8 cases himself at that time. The first patient was a member of the hospital's board of trustees. ↗
▶ Ep 3 · 30:31
clinical Ponsky became director of surgical endoscopy at University Hospitals at age 29 as a new attending. ↗
▶ Ep 3 · 31:23
clinical The PEG (percutaneous endoscopic gastrostomy) was developed in May 1979 by Ponsky and pediatric gastroenterologist Mike Gower, with the first five cases performed on babies with birth asphyxia and psychomotor retardation. ↗
▶ Ep 3 · 31:31
clinical The PEG procedure was developed without IRB approval, only discussing the approach with patients' families. ↗
▶ Ep 3 · 31:50
clinical Ponsky became chief of surgery at Mount Sinai Hospital at age 32 in 1979. ↗
▶ Ep 3 · 32:54
clinical Mount Sinai Hospital had an animal laboratory that was larger than Cleveland Clinic's laboratory, providing Ponsky freedom to conduct courses and train fellows. ↗
▶ Ep 3 · 40:27
clinical The distal splenorenal shunt, once considered a great operation based on physiology to reduce variceal pressure without decreasing portal flow, became obsolete when endoscopic variceal banding was introduced. ↗
▶ Ep 3 · 41:05
clinical Ponsky performed 180 vertical banded gastroplasties in one year in the mid-1980s, an operation that later required reversal in many patients. ↗
▶ Ep 3 · 41:34
clinical Ponsky performed 1,600 colonoscopies in a single year during his practice. ↗
▶ Ep 3 · 43:09
clinical ERCP was developed primarily in Japan by Itaru Oi and colleagues, with contributions from German physicians and Peter Cotton's group in London. ↗
▶ Ep 3 · 43:40
clinical Ponsky learned ERCP primarily through watching videos and self-teaching, then traded training with George Brodmerkel in Pittsburgh—teaching him laparoscopy under local anesthesia in exchange for learning sphincterotomy. ↗
▶ Ep 3 · 48:24
clinical Early SAGES meetings focused on surgical problem-solving with endoscopy, addressing topics like managing bowel obstruction, evaluating suture lines, and treating intestinal volvulus endoscopically—distinct from ASGE's focus. ↗
▶ Ep 3 · 50:09
clinical Ponsky advocated to the Residency Review Committee (when Joe Fisher was head) for a minimum endoscopy requirement in general surgery training. The initial requirement of 50 cases was controversial but established endoscopy as a required component of general surgery. ↗
▶ Ep 3 · 51:55
quote Always volunteer, never say no, get involved in everything. And you know what, you'll find the time. You don't have to belabor decisions. Make a decision and move on. ↗

Residency Advice: Dr. Jeffrey Ponsky | St. George's University

▶ Ep 4 · 0:21
opinion The interview is a small part of the whole process of selecting people for residency. ↗
▶ Ep 4 · 0:29
quote What we want is people who What's that, uh, Friday Night Lights, Bright eyes and full hearts ↗
▶ Ep 4 · 0:29
opinion Residency programs want candidates with bright eyes and full hearts, meaning desire and enthusiasm. ↗
▶ Ep 4 · 0:46
guideline Candidates must have passed their USMLE and have good letters of recommendation as baseline requirements. ↗
▶ Ep 4 · 0:52
quote Don't ask people to write you a letter of recommendation. They're going to write you bad letters. I mean, hello, that's an intelligence test, and you'd be surprised how many people don't realize that. ↗
▶ Ep 4 · 0:52
opinion Asking people who will write bad letters of recommendation to write for you is an intelligence test that many candidates fail. ↗
▶ Ep 4 · 1:08
guideline During interviews, candidates should make eye contact and look interested in what the interviewer is doing. ↗
▶ Ep 4 · 1:21
quote We want a partner in the education. You talk to the educators out here, there's nothing better than having a partner in the education. Somebody who looks at you and says, yes, come on, give it to me. I wanna be, I want it. ↗
▶ Ep 4 · 1:21
opinion Residency programs want a partner in the education process. ↗
▶ Ep 4 · 1:37
opinion Interviewers want to know that candidates are willing to invest in their own education. ↗
▶ Ep 4 · 1:42
guideline Candidates should give interviewers a plan and vision for their future during the interview. ↗
▶ Ep 4 · 1:58
opinion An enthusiastic, engaged candidate can overcome merely adequate grades in the selection process. ↗
▶ Ep 4 · 1:58
quote This guy was so electric. He really can't, you know, I know his grades were just OK, but this guy, I want to work with this guy. I like him. That's what they want to hear. ↗
▶ Ep 4 · 2:09
guideline During interviews, candidates should not be shy but also should not be a jerk. ↗
▶ Ep 4 · 2:09
quote Don't be, this isn't the time to be shy. OK, it's, it's not time to be a jerk, but it's not a time to be shy, so get involved. This is your chance. The interview is important. ↗

SAGES Stories: Dr. Jeffrey Ponsky on surgical endoscopy and the PEG tube legacy

▶ Ep 5 · 6:49
quote I was the worst damn student uh around. ↗
▶ Ep 5 · 6:49
clinical Ponsky graduated Cleveland Heights High School with a 2.027 GPA and was advised by his counselor to consider trade school instead of college. ↗
▶ Ep 5 · 7:03
quote I had a 2.027 with my with my acu graduating from high school ↗
▶ Ep 5 · 9:01
quote look, I'm gonna do this. As best I can do. I don't know what I'm gonna do. All I know is that I'm gonna work my butt off, and I'm not gonna screw around and I'm not gonna party cause I've done that my whole life and now I was just gonna study ↗
▶ Ep 5 · 9:44
quote I ate the book so I could spit it out ↗
▶ Ep 5 · 9:44
opinion Ponsky's transformation in college came from memorizing everything and studying constantly, discovering he had an 'unbelievable' memory that allowed him to 'eat the book and spit it out.' ↗
▶ Ep 5 · 10:05
quote I could eat the book and spit it out. ↗
▶ Ep 5 · 10:59
clinical Working as an orderly at Mount Sinai Hospital, Ponsky gave bed baths, changed bedpans, and cared for a high school classmate who became paraplegic after an auto accident, which deepened his commitment to medicine. ↗
▶ Ep 5 · 12:15
clinical Ponsky was promoted to scrub tech and surgeons allowed him to close fascia, despite the head nurse objecting that he wasn't permitted to do so. ↗
▶ Ep 5 · 12:43
clinical Ponsky never took calculus, using logarithms to work around it in physics, and the Case Western dean of admissions accepted him despite this after he stated he had already been admitted to two other medical schools. ↗
▶ Ep 5 · 14:14
clinical Ponsky chose Case Western Reserve (then Western Reserve) over Northwestern and Cincinnati primarily because his family lacked money and he needed to live at home rather than pay rent elsewhere. ↗
▶ Ep 5 · 19:43
opinion Bill Holden, chairman of surgery at Case, was an 'elegant' teacher who used the Socratic method and prioritized teaching over technical skill. ↗
▶ Ep 5 · 20:20
clinical Walter Parry taught using theatrical methods, including having students smell a room to perceive 'the smell of death' (though there was no actual smell) and performing bedside pinch grafts on bedsores at Metro Hospital. ↗
▶ Ep 5 · 20:54
quote that's the smell of death. ↗
▶ Ep 5 · 22:33
clinical Parry made Ponsky rewrite his first paper—a letter to the New England Journal about paradoxical air embolism—six times and read German poetry to him to encourage more poetic medical writing. ↗
▶ Ep 5 · 25:08
clinical When Ponsky requested an endoscopy elective as a resident, the head of GI at University Hospitals refused, stating 'we're not training any surgeons.' ↗
▶ Ep 5 · 25:47
clinical Charles Hube arranged for Ponsky to train with Jim King in Canton, Ohio, where Ponsky performed approximately 500 colonoscopy cases over 5-6 months using a mid-length scope not designed to reach the cecum. ↗
▶ Ep 5 · 26:19
clinical After returning from Canton, the head of gastroenterology told Ponsky 'you're not gonna touch this scope,' so he used the VA's Olympus colonoscope instead. ↗
▶ Ep 5 · 26:51
clinical Ponsky's mother-in-law purchased his first colonoscope after hearing at a family dinner that he couldn't get access to equipment; in that era, scopes were washed with green soap and stored in car trunks. ↗
▶ Ep 5 · 27:13
clinical As a senior resident, Ponsky performed emergency endoscopy cases day and night with Bob Zollinger Junior signing the paperwork, eventually doing all cases while GI physicians stopped performing them. ↗
▶ Ep 5 · 28:30
clinical When SAGES started, it had approximately 300 members; when Ponsky became president in 1990, the society was giving courses on surgical endoscopy and its relationship to surgical problem-solving. ↗
▶ Ep 5 · 28:48
clinical At the 1990 SAGES meeting in Louisville, Kentucky, Jacques Perissat showed video of laparoscopic cholecystectomy in the exhibit hall; Ponsky was SAGES president at the time and 'right in on the ground floor.' ↗
▶ Ep 5 · 29:06
clinical Early laparoscopic instruments were unavailable for purchase, so surgeons used gynecology instruments. Ponsky took one of the first training courses taught by Nat Soper, George Berci, John Hunter, and John Sackier in Salt Lake City. ↗
▶ Ep 5 · 29:27
clinical Ponsky's first two laparoscopic cholecystectomy cases at Mount Sinai were performed on a board of trustees member, proctored by David Dupper who had completed only eight cases himself. ↗
▶ Ep 5 · 31:11
clinical The PEG tube was invented in May 1979 when Ponsky and pediatric surgeon Michael Gower used transillumination (seeing light shine through the abdominal wall during endoscopy in neonates) to develop a minimally invasive gastrostomy technique, performing it on five babies with birth asphyxia and psychomotor retardation. ↗
▶ Ep 5 · 31:31
clinical The PEG tube procedure was performed without IRB approval; Ponsky and Gower only spoke with the patients' families before proceeding. ↗
▶ Ep 5 · 31:50
clinical Ponsky became chief of surgery at Mount Sinai Hospital at age 32, shortly after inventing the PEG tube. ↗
▶ Ep 5 · 32:44
quote the favorite place I ever worked in my life was Mount Sinai. ↗
▶ Ep 5 · 32:44
opinion Mount Sinai was Ponsky's 'favorite place I ever worked in my life'—a small hospital where every staff member knew each other, with an animal research laboratory larger than Cleveland Clinic's. ↗
▶ Ep 5 · 33:36
opinion Ponsky left Mount Sinai in 1997 after 18 years when the hospital was sold to a for-profit company whose leadership 'could care less about quality.' ↗
▶ Ep 5 · 33:36
quote They were for-profit guys who could care less about quality. ↗
▶ Ep 5 · 34:21
clinical Ponsky had all but one of his children before finishing residency; his last son was born during his final year of residency, and his daughter was born three years later after he joined Mount Sinai. ↗
▶ Ep 5 · 34:43
opinion Ponsky's wife had no partners helping her while he was on call every other night, but he credits his family—wife, children, and in-laws—as essential to his success, stating 'our success was a joint success, not just my success.' ↗
▶ Ep 5 · 34:49
quote You know, here's the important part. You, you gotta have a good partner. To have all the success doesn't come down cause you're a genius. You have to either destroy your family as many people did in the past, or use that to bolster your success ↗
▶ Ep 5 · 35:09
quote our success was a joint success, not just my success. ↗
▶ Ep 5 · 35:30
quote Who's watching our patients when we go? We all have a partner who's making rounds and taking our patients back when we have Complications ↗
▶ Ep 5 · 36:32
opinion Ponsky's greatest academic achievement was becoming chairman of the Department of Surgery at Case Western Reserve, though his parents were most proud of his role as chief of surgery at Mount Sinai because it was meaningful within the Jewish community they knew. ↗
▶ Ep 5 · 36:39
quote I think that, uh, I was chair of the board of the board of surgery. They wouldn't have understood that. That to them didn't mean anything. They saw it as the chief of surgery at Mount Sinai, that's enough. ↗
▶ Ep 5 · 38:47
opinion Ponsky has counseled fellows away from positions at his own institutions when he believed better opportunities existed elsewhere, considering factors like family proximity, academic opportunity, and institutional need rather than institutional prestige. ↗
▶ Ep 5 · 38:58
quote that is not the best opportunity for you. There is a great opportunity here because they need you more, because this is a better academic opportunity, because the people you'll be working with are more uh akin to what you need, or your family is in that city, your husband or wife's family is in that city. ↗
▶ Ep 5 · 39:32
quote go where the opportunities are best for your whole life, not just for your name of your institution. ↗
▶ Ep 5 · 40:27
quote I thought that a distal splenor renal shunt was a great operation when they first did it. I dare say you've not done those. ↗
▶ Ep 5 · 40:27
clinical Ponsky performed distal splenorenal shunts early in his career at University Hospitals with Jerry Walkoff's assistance, believing the operation was 'the greatest thing since sliced bread' based on Dean Warren's physiologic approach, but the procedure became obsolete when endoscopic variceal banding was introduced. ↗
▶ Ep 5 · 41:05
clinical Ponsky performed 180 vertical banded gastroplasty procedures in one year during the mid-1980s, believing it would be a great bariatric operation, but later surgeons had to reverse many of them. ↗
▶ Ep 5 · 41:34
opinion Ponsky performed 1600 colonoscopies in his final year of practice, predicting that in 20 years colonoscopy for screening may be obsolete. ↗
▶ Ep 5 · 41:34
quote I dare say in 20 years, you may say, I remember when we did colonoscopy for screening on all these patients ↗
▶ Ep 5 · 42:07
opinion ERCP is Ponsky's favorite procedure, which he describes as 'like golf for some people'—he would come in day or night to perform it and considers it a sophisticated procedure requiring 'body English.' ↗
▶ Ep 5 · 42:10
quote To me, ERCP is like golf for some people. I love ERCP. I would have come in day or night to do ERCP. I just loved it. ↗
▶ Ep 5 · 43:40
clinical Ponsky learned ERCP largely self-taught by watching videos, then arranged a teaching exchange with George Brodmerkel in Pittsburgh: Ponsky taught Brodmerkel laparoscopy under local anesthesia for liver biopsy, and Brodmerkel taught Ponsky sphincterotomy. ↗
▶ Ep 5 · 44:19
quote ERCP is like a a a a golf game. Is it body English in it. There it's very sophisticated and I love it. ↗
▶ Ep 5 · 44:54
opinion Ponsky obtained an executive MBA at the urging of hospital administrators who said he made decisions 'out of your gut' without understanding return on investment or financing; he describes the MBA as learning 'the language of business' and when to 'say bullshit at the right time' in business meetings. ↗
▶ Ep 5 · 45:36
quote I hate business. I don't care about business. ↗
▶ Ep 5 · 46:18
quote It's the people you meet. Yeah, it's the way they think. It's the way they approach a problem. ↗
▶ Ep 5 · 47:50
quote I felt a little bit like a traitor to ASGE because here are these group of surgeons who decided they're gonna start their own society. ↗
▶ Ep 5 · 47:50
opinion Ponsky initially felt like a 'traitor' to ASGE when SAGES started because he was already on the ASGE governing board. ↗
▶ Ep 5 · 48:24
opinion At early SAGES meetings, papers focused on surgical problem-solving with endoscopy (bowel obstruction evaluation, suture line assessment, volvulus management)—topics distinct from ASGE content—which convinced Ponsky of the society's unique value. ↗
▶ Ep 5 · 48:46
quote There is a reason for this society, intraoperative endoscopy, things that we would do. ↗
▶ Ep 5 · 50:02
quote Endoscopy has been made a part of surgery now and general surgery. It is a requirement for general surgery. ↗
▶ Ep 5 · 50:09
clinical Ponsky advocated to the Residency Review Committee (when Joe Fisher was head) for a minimum endoscopy case requirement in general surgery training; the 50-case requirement was initially controversial but established endoscopy as a core surgical competency. ↗
▶ Ep 5 · 50:45
quote The endoscope is now. The vehicle, it's the car that gets us to our destination. It drives us to our destination, then we put it down, we have it fixed, and we start to operate endoscopically ↗
▶ Ep 5 · 51:38
quote There's no reason that you can't be empathetic and be interested in psychiatric disease and still be somebody interested in the technical sides. ↗
▶ Ep 5 · 51:55
quote All I tell people is always volunteer, never say no, get involved in everything. And you know what, you'll find the time. ↗
▶ Ep 5 · 51:55
opinion Ponsky's philosophy is to 'always volunteer, never say no, get involved in everything'—he believes people will find the time, decisions don't need to be belabored, and residents can help with much of the work. ↗
▶ Ep 5 · 51:58
quote I think that surgeons can be better psychiatrists than some of the psychiatrists now. They're more empathetic in some ways ↗
▶ Ep 5 · 52:57
quote Don't be afraid to do everything. Don't say I'm too busy. You can do everything. ↗
▶ Ep 5 · 54:00
quote I don't take myself too seriously, and you shouldn't, because there are really other people around who've done many more things than me ↗
▶ Ep 5 · 55:18
quote if you don't have hobbies, you're cheating yourself. ↗
▶ Ep 5 · 55:24
clinical Ponsky's wife purchased him a Harley-Davidson trike (three-wheeled motorcycle) when he turned 70; she would not permit a two-wheel motorcycle. They have ridden to Sturgis, South Dakota. ↗
▶ Ep 5 · 56:04
quote The answer is no. I've never been tempted. Uh, to move because my family is here. It's all about your family. ↗
▶ Ep 5 · 56:12
clinical Ponsky lives on 8 acres with horses; his son Zach built a house on the adjacent 5-acre lot, his daughter bought a house two properties away with another 5 acres, son Todd lives within half a mile, and son Lee lives 'almost 2 miles' away—creating a family compound in Cleveland. ↗
▶ Ep 5 · 57:22
clinical Ponsky has a house in Florida and would travel there for long weekends during his working years, leaving Friday morning at 6 AM and returning Monday, using vacation days for Friday and Monday. ↗
▶ Ep 5 · 58:08
quote My family only wants to be near my wife. They can care less about me unless Jackie, unless something breaks. Then they call me, but they only want to be near my wife. ↗
▶ Ep 5 · 58:21
quote She's I'm gonna be very clear about that. She's pretty great, the glue that holds our family together ↗
▶ Ep 5 · 59:19
quote My favorite memories, my presidential addresses or highlights of my career. I love doing that. ↗
▶ Ep 5 · 59:45
quote We Are the Sages with the Japanese, because I go to tears when we do that every year, because that is not just a song, that is our soul, and that song says why we are different from all other societies, that says that we are a family. ↗

The invention of the PEG tube with Dr. Jeffrey Ponsky

▶ Ep 7 · 2:43
quote I was told I couldn't do it because I was a surgical resident, and that piqued my interest ↗
▶ Ep 7 · 3:02
quote I came back after that training and I was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments ↗
▶ Ep 7 · 3:27
clinical In 1974-1975, there were no pediatric gastroenterologists, and Ponsky performed endoscopy on children, young adults, and neonates with GI problems using his personally owned scope. ↗
▶ Ep 7 · 4:33
clinical During neonatal endoscopy, the room would light up because babies were so thin; when pediatric surgeon Michael Gower pushed on the transilluminated light with his finger, an indentation was visible endoscopically. ↗
▶ Ep 7 · 4:42
quote Michael would push on the light with his finger, and I'd be scoping and I would see an indentation. And we realized we got together and said, you know, maybe we could do something with this. ↗
▶ Ep 7 · 4:59
clinical The first PEG tubes were constructed from OR gastrostomy tubes (small Pezzer catheters) with sutures threaded through the end and passed through an IV catheter (medicut) to create a dilator tip. ↗
▶ Ep 7 · 5:42
clinical The first five PEG procedures in May 1979 were performed in neonates with severe psychomotor retardation who were brain dead, fed by nasogastric tubes, had no chance of recovery, and were being sent for open gastrostomy before long-term nursing facility placement. ↗
▶ Ep 7 · 6:15
quote we have to do a major laparotomy on these babies, uh, but we have an idea for performing this, uh, by a new technique. Uh, we don't have any idea if it'll work. We think it will, it's pretty simple, but if it doesn't, we will do the laparotomy right there and then and complete the gastrostomy ↗
▶ Ep 7 · 6:25
clinical Informed consent for the first PEG cases consisted of telling mothers that if the new technique failed, immediate laparotomy and open gastrostomy would be performed. ↗
▶ Ep 7 · 6:37
quote That was the informed consent at that time. ↗
▶ Ep 7 · 6:42
clinical The first PEG procedures succeeded easily within a few minutes. ↗
▶ Ep 7 · 6:47
clinical After the initial five neonatal cases, Ponsky moved to Mount Sinai Medical Center and began performing PEG in adult stroke patients with similar neurologic prognosis who needed feeding access. ↗
▶ Ep 7 · 7:13
clinical Laboratory studies on PEG tract formation, tube dwell time before safe replacement, and leakage risk were conducted after clinical implementation—the reverse of typical research-then-clinical sequence. ↗
▶ Ep 7 · 7:28
clinical John Mellinger, who later worked at the American Board of Surgery, conducted original research on PEG tract formation. ↗
▶ Ep 7 · 7:44
quote it was sort of the reverse of what you would do now by going to the laboratory first and then And then to the operating room. ↗
▶ Ep 7 · 8:18
quote We didn't have IRBs in those days. ↗
▶ Ep 7 · 8:39
clinical Multiple medical device companies refused to manufacture the PEG tube initially, believing nobody would use it. ↗
▶ Ep 7 · 8:54
clinical A small company in Mentor, Ohio eventually manufactured the PEG tube exactly as designed by Ponsky and Gower. ↗
▶ Ep 7 · 9:06
opinion Ponsky and Gower never patented the PEG tube; they were more interested in publication than patents and wanted to disseminate the technique. ↗
▶ Ep 7 · 9:06
quote we never even thought about patenting the tube. It wasn't even on our mind. ↗
▶ Ep 7 · 9:18
quote We wanted to get papers out of it. We wanted to make a contribution to literature. We were more interested in publication than patents ↗
▶ Ep 7 · 9:39
clinical PEG tube complications included rare colonic perforation when the tube traversed the colon en route to the stomach, which still occurs rarely today. ↗
▶ Ep 7 · 9:51
clinical Exit-site infection was a major early PEG complication. ↗
▶ Ep 7 · 10:24
clinical PEG tubes evolved from multi-piece rubber construction to one-piece silicone, but have had very few modifications in the last few years and have become a commodity product purchased by hospitals at the lowest price. ↗
▶ Ep 7 · 10:50
clinical The PEG technique has remained very much the same as the original with only a few modifications. ↗
▶ Ep 7 · 11:19
clinical Ponsky and the manufacturing company conducted dozens of animal experiments to determine tube removal pressure, tip retention, and optimal tube size for FDA approval. ↗
▶ Ep 7 · 12:09
quote I said, wow, look at this. What else can we do with this thing? ↗
▶ Ep 7 · 12:13
quote the peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract. ↗
▶ Ep 7 · 12:13
clinical The PEG tube was the first and only time any instrument or needle was thrust through the abdominal wall into the GI tract and left in place. ↗
▶ Ep 7 · 12:55
clinical In 1975, Ponsky developed and published endoscopic tattooing using India ink injected alongside polypectomy sites to mark the location for potential surgical resection if cancer was found; the technique remains in use today. ↗
▶ Ep 7 · 13:38
quote there was a lot of low hanging fruit then we could do things that seemed logical, and that's the fun of a new area. ↗
▶ Ep 7 · 13:56
quote everybody thinks that everybody's been, everything's been discovered already, that's not true. ↗
▶ Ep 7 · 15:31
clinical In the late 1970s, surgical residents were on call every other night (36 hours on, 12 hours off) for five years of training. ↗
▶ Ep 7 · 15:49
quote I wanna have an elective that's a little bit easier. ↗
▶ Ep 7 · 15:58
quote I said, wow, that would be a great way to blow up 3 months. I won't have to take night off. This will be easier. That was an accident. ↗
▶ Ep 7 · 17:07
quote when you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it. ↗
▶ Ep 7 · 17:35
clinical In the mid-1970s, the predominant American endoscope was the ACMI (American Cystoscope Makers Incorporated) with a joystick control, approximately 1 cm diameter, with image quality like looking through ground glass. ↗
▶ Ep 7 · 18:00
quote it was like looking through ground glass. ↗
▶ Ep 7 · 18:03
clinical Japanese companies (Mashida and Olympus in the US) produced fiber-optic endoscopes with crystal-clear optics that were markedly superior to American models. ↗
▶ Ep 7 · 18:15
quote It was crystal clear. It was like you were just right there. ↗
▶ Ep 7 · 18:21
quote I bought the best instrument. ↗
▶ Ep 7 · 18:26
clinical 1970s fiber-optic endoscopes transmitted light via fiber bundles to the lumen and returned images to the eyepiece; photography required clipping a camera to the eyepiece for film-strip images. ↗
▶ Ep 7 · 18:51
clinical Teaching attachments for 1970s endoscopes consisted of a wire-connected second eyepiece that provided a dim image for trainees in darkened rooms. ↗
▶ Ep 7 · 19:06
clinical Around 1980, video chip technology placed a camera at the endoscope tip instead of using fiber-optic image transmission, displaying images on large monitors—the technology used in current endoscopes. ↗
▶ Ep 7 · 19:36
clinical In the late 1970s, neonates could tolerate endoscopes approximately 9 millimeters wide, which was the limit for safe use. ↗
▶ Ep 7 · 19:57
clinical The original PEG procedure was performed with an adult endoscope. ↗
▶ Ep 7 · 20:07
quote I would almost not let anyone touch it except me ↗
▶ Ep 7 · 20:56
clinical In the 1970s, endoscopes were cleaned between procedures using only green soap; high-level disinfection and sterilization protocols did not yet exist. ↗
▶ Ep 7 · 21:45
clinical The PEG tube received FDA 510(k) approval as a modification of existing gastrostomy tubes used for similar purposes, which is easier than approval for entirely novel devices. ↗
▶ Ep 7 · 22:17
clinical PEG indications expanded beyond feeding to include gastric decompression in gastroparesis or obstruction (including carcinomatosis), delivery of unpalatable feedings, and treatment of gastric volvulus. ↗
▶ Ep 7 · 23:00
clinical The PEG technique was adapted for colonic applications including sigmoid volvulus fixation and Ogilvie syndrome decompression, with multiple PEGs used for sigmoid volvulus. ↗
▶ Ep 7 · 23:30
quote I like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation. That's what we think of as surgeons. ↗
▶ Ep 7 · 23:56
opinion Many endoscopic procedures developed by surgeons, including PEG, were extensions of surgical operations already performed via laparotomy. ↗
▶ Ep 7 · 25:32
clinical Gastroenterologists rapidly adopted PEG as a therapeutic procedure they could easily accomplish, driving widespread dissemination. ↗
▶ Ep 7 · 25:56
clinical Surgeons were slower to adopt PEG initially because they were not performing as much therapeutic endoscopy at that time, but they did not offer significant resistance. ↗
▶ Ep 7 · 26:40
clinical A properly performed PEG procedure takes under 5 minutes when done carefully by an experienced operator. ↗
▶ Ep 7 · 26:47
clinical Current PEG procedures still require patient sedation or anesthesia and constitute an intervention. ↗
▶ Ep 7 · 26:58
quote I want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local ↗
▶ Ep 7 · 27:31
quote don't stop dreaming and stop thinking. ↗
▶ Ep 7 · 27:43
opinion Radiologists perform gastrostomy tube placement using ultrasound guidance, though Ponsky does not prefer the tubes they use. ↗
▶ Ep 7 · 32:57
quote you should always uh take a chance. Now, you shouldn't take a chance with patients' lives, but you should take a chance on developing new ideas and new procedures and new instruments. ↗

Jeffrey Ponsky: Portrait of a SAGES Pioneer

▶ Ep 18 · 0:13
quote I was told not to go to college, uh, maybe trade school. ↗
▶ Ep 18 · 5:52
clinical Ponsky's mother-in-law purchased his first endoscope for $5,200 as a Christmas/Hanukkah gift after he was blocked from using the university gastroenterology department's equipment. ↗
▶ Ep 18 · 7:46
clinical In 1979, Ponsky and Michael Gauderer performed the first percutaneous endoscopic gastrostomy (PEG) procedures in five brain-damaged infants who were scheduled for open gastrostomy, after observing transillumination of the abdominal wall during upper endoscopy. ↗
▶ Ep 18 · 8:40
clinical The first PEG procedures in 1979 were performed without formal IRB review; consent was obtained by explaining to mothers that the team would attempt the endoscopic approach but would convert to open gastrostomy if unsuccessful. ↗
▶ Ep 18 · 10:18
guideline The American Board of Surgery mandated around 1980 that surgical residents must have experience in endoscopy, but most programs rotated residents to gastroenterology services where they only observed rather than performed procedures. ↗
▶ Ep 18 · 11:35
clinical SAGES was founded around 1980 by Jerry Marks and other surgeons including John Coller, Ken Ford, John Van Sant, and Jim Lynn because ASGE did not want surgical papers on their programs frequently and excluded surgeons from leadership roles. ↗
▶ Ep 18 · 13:55
clinical Barbara Saltzman (later Barbara Bercy after marrying George Bercy) served as SAGES administrator from the early years and was critical to establishing the organization's culture and managing its growth. ↗
▶ Ep 18 · 15:17
epidemiological During Ponsky's 18-month SAGES presidency (approximately 1989-1990), membership grew from 300 to 2000 members, driven by the introduction of laparoscopic cholecystectomy after Jacques Perrissat showed his video at a Louisville meeting in 1989. ↗
▶ Ep 18 · 16:43
opinion SAGES developed a flat organizational structure unlike hierarchical traditional surgical societies, encouraging young surgeons to participate equally on committees and at social events regardless of seniority. ↗
▶ Ep 18 · 18:05
clinical SAGES changed its name from Society of Gastrointestinal Endoscopic Surgeons to Society of Gastrointestinal and Endoscopic Surgeons in the last decade, making both endoscopy and general GI surgery equal parts of the organization's mission. ↗
▶ Ep 18 · 18:35
epidemiological Current SAGES membership is close to 7,000 members. ↗
▶ Ep 18 · 22:17
clinical Japanese surgeons, particularly through Choichi Segawa, Manabu Yamamoto, and others, were instrumental in teaching SAGES members advanced endoscopic techniques including POEM and endoscopic submucosal dissection. ↗
▶ Ep 18 · 31:14
clinical Three of Ponsky's fellows became SAGES presidents: John Mellinger, Brian Duncan, and Jeff Marks. ↗
▶ Ep 18 · 35:59
opinion Walter Pore, in his mid-80s, continues to hold NIH grants and remains relevant in research and lecturing, demonstrating that surgeons can maintain professional relevance well into advanced age. ↗
▶ Ep 18 · 37:57
clinical George Bercy at age 96 continues to develop new surgical instruments and regularly contacts Ponsky to review new designs, including a smaller chip-camera choledochoscope and a VTO scope for cardiac surgeons to view valve anastomoses without loupes. ↗
▶ Ep 18 · 38:49
quote He doesn't look at the instrument for what it is today. He looks at the instrument for what it could be with improvement. ↗
▶ Ep 18 · 39:01
clinical The video camera was essential to the laparoscopic revolution because it allowed the entire surgical team to see what the surgeon was doing, unlike earlier laparoscopy where only the surgeon looking through the eyepiece could see the operative field. ↗
▶ Ep 18 · 39:49
clinical Eddie Joe Reddick and Doug Olson in Nashville, and Barry McKernan and Bill Saye in Marietta, Georgia (who did the first laparoscopic cholecystectomy in the United States) were the key early teachers of the procedure. ↗
▶ Ep 18 · 40:17
clinical SAGES initially trained trainers (including John Hunter, Nat Soper, John Saker, George Bercy) in laparoscopic cholecystectomy before offering courses to the broader surgical community. ↗
▶ Ep 18 · 40:57
clinical In the early laparoscopic era, instrument shortages were severe; surgeons needed personal connections to manufacturers to obtain equipment and often used gynecologic instruments adapted for general surgery. ↗
▶ Ep 18 · 42:06
clinical In early laparoscopic common bile duct exploration, before mastering laparoscopic suturing, surgeons would twist the two suture ends together like a twist-tie and secure them with a clip rather than tying knots. ↗
▶ Ep 18 · 42:46
clinical Ponsky was the first SAGES member appointed to the American Board of Surgery and later served as chairman of the board. ↗
▶ Ep 18 · 45:32
quote The day that you resigned from your great position as chairman. And you expect them to sing your praises forever. What they're really talking about is who's the next in line for your office. ↗

Special Lecture: Dr. Jeffrey Ponsky | St. George's University

▶ Ep 21 · 6:36
quote So you think you're the first guys that wanted the truth? ↗
▶ Ep 21 · 9:12
quote The truth is often based on what we can perceive it with. If we have tools, new tools to perceive it. Then our idea of what the truth is changes. ↗
▶ Ep 21 · 9:12
opinion Medical truth is based on what tools we have to perceive it with—when we have new tools to perceive truth, our idea of what the truth is changes. ↗
▶ Ep 21 · 10:51
quote So ask yourself, 120 years ago, When William Halstead was at Hopkins and William Osler Was at Hopkins? What did they teach medical students for 4 years? ↗
▶ Ep 21 · 10:51
clinical 120 years ago at Johns Hopkins, medical education focused heavily on anatomy because physicians lacked knowledge of the Krebs cycle, cytochrome system, blood transfusion, blood typing, antibiotics, and pharmacology. ↗
▶ Ep 21 · 13:07
clinical In 1889, William Osler and William Halsted believed gastric acid caused peptic ulcer disease. ↗
▶ Ep 21 · 13:16
quote What causes peptic ulcer disease today? Gastric acid was the truth then. Gastric acid was absolutely the truth. ↗
▶ Ep 21 · 13:32
clinical H. pylori was discovered in 1990 as a cause of peptic ulcer disease; it blocks production of prostaglandin E3, destroying the mucosal barrier and allowing acid to cause ulcers. ↗
▶ Ep 21 · 13:34
quote In 1990, they discovered H. pylori. They said it was the greatest thing since the discovery of the cure for polio. I'm not sure that's true. ↗
▶ Ep 21 · 16:15
clinical Gastrojejunostomy was the first operation for peptic ulcer disease, designed to rapidly drain gastric acid from the stomach, but it failed with a 50% recurrence rate due to marginal ulcers developing in unbuffered small bowel. ↗
▶ Ep 21 · 18:32
clinical Subtotal gastrectomy (removing 80% of the stomach) had a 99% success rate in preventing ulcers because it removed the parietal cells that produce acid. ↗
▶ Ep 21 · 19:01
clinical Subtotal gastrectomy had high mortality due to lack of intensive care units, IV fluids, and antibiotics; survivors often suffered malnutrition (inanition) severe enough to cause death. ↗
▶ Ep 21 · 19:38
epidemiological Approximately 15% of patients after subtotal gastrectomy developed dumping syndrome with severe cramps, sweating, hypotension, and diarrhea. ↗
▶ Ep 21 · 19:52
clinical Early dumping syndrome (20 minutes to 2 hours post-meal) is caused by inappropriate release of vasoactive intestinal polypeptide (VIP) from the pancreas, not by hypertonic fluid dumping into the small bowel as originally thought. ↗
▶ Ep 21 · 21:05
clinical Late dumping syndrome (2-4 hours post-meal) results from insulin-glucose imbalance: the intestine releases gastric inhibitory polypeptide (GIP) which stimulates pancreatic insulin release disproportionate to glucose absorption, causing insulin shock with hypoglycemia, hypotension, and tachycardia. ↗
▶ Ep 21 · 22:58
clinical The subtotal gastrectomy operation was later adapted as the basis for gastric bypass surgery in bariatric treatment of morbid obesity, born out of the observation that the operation caused significant weight loss. ↗
▶ Ep 21 · 24:00
clinical Pavlov discovered the phases of digestion; the cephalic phase occurs when sight or smell of food stimulates the vagus nerve via the area postrema of the fourth ventricle, causing salivation and gastric acid secretion. ↗
▶ Ep 21 · 25:34
clinical The gastric phase of digestion occurs when food distends the stomach, buffers acid (raising pH), and peptones stimulate G cells in the antrum to secrete gastrin, a heptadecapeptide (17 amino acids) that stimulates parietal cell H2 receptors to produce acid. ↗
▶ Ep 21 · 26:48
clinical Lester Dragstedt designed truncal vagotomy to ablate the cephalic phase of digestion by cutting both vagus nerves, but this caused the stomach to become atonic and unable to empty, requiring addition of a drainage procedure (gastrojejunostomy or pyloroplasty). ↗
▶ Ep 21 · 28:56
epidemiological Truncal vagotomy with drainage had a 15% recurrence rate for peptic ulcer disease. ↗
▶ Ep 21 · 29:13
clinical Complications of truncal vagotomy included severe diarrhea from denervating the celiac plexus, gallstones from denervating the liver, and dumping syndrome (15% of patients) from bypassing or destroying the pylorus. ↗
▶ Ep 21 · 30:10
clinical Antrectomy (removing the lower 40% of stomach containing G cells) combined with truncal vagotomy ablates both cephalic and gastric phases of digestion, achieving a 98% cure rate (2% recurrence) for peptic ulcer disease. ↗
▶ Ep 21 · 31:29
epidemiological Antrectomy with truncal vagotomy still caused dumping in 15% of patients and diarrhea in some patients. ↗
▶ Ep 21 · 32:38
clinical Selective vagotomy preserves the celiac and hepatic vagal branches while denervating only the stomach, reducing complications of gallstones and diarrhea while maintaining a 15% recurrence rate. ↗
▶ Ep 21 · 34:01
clinical The nerve of Latarjet, described by a French anatomist 100 years ago, is the terminal vagal branch that provides motor function to the pylorus but does not stimulate acid production because it innervates the antrum, which lacks parietal cells. ↗
▶ Ep 21 · 35:17
clinical Highly selective vagotomy denervates the acid-producing portion of the stomach while preserving the nerve of Latarjet, eliminating the cephalic phase of acid secretion while maintaining pyloric motor function, thus avoiding the need for drainage procedures and reducing dumping syndrome. ↗
▶ Ep 21 · 35:42
opinion Highly selective vagotomy represents a synthesis of old anatomic knowledge (histology of parietal cell distribution, nerve of Latarjet anatomy) with modern physiology and endocrinology. ↗
▶ Ep 21 · 36:12
quote So when you study in medical school and you say, well, I don't need to know that anymore, that's old stuff. What is important is anatomy important? You better learn it if you want to make a contribution. ↗
▶ Ep 21 · 37:07
opinion Discovery favors the prepared mind—knowing old information (anatomy, physiology, endocrinology) enables physicians to design new approaches by recombining old and new knowledge. ↗
▶ Ep 21 · 37:07
quote Discovery favors the prepared mind. If you know where the parietal cells are and where they're not, and you know what that nerve does and where it is, you can design something new based on a lot of old information. ↗
▶ Ep 21 · 37:48
guideline Surgery for peptic ulcer disease is now indicated only for complications: hemorrhage, obstruction, perforation, and intractability, the same indications as 120 years ago. ↗
▶ Ep 21 · 38:58
clinical Modern surgical practice for peptic ulcer obstruction involves pyloroplasty combined with H. pylori treatment and proton pump inhibitors rather than vagotomy, reflecting evolution of treatment approaches. ↗
▶ Ep 21 · 41:30
quote Don't ask people to write you a letter of recommendation. They're gonna write you bad letters. I mean, hello, that's an intelligence test, and you'd be surprised how many people don't realize that. ↗
▶ Ep 21 · 44:04
opinion Students who actively participate and risk being wrong during teaching sessions retain information better than passive observers because emotional investment (anxiety, satisfaction) enhances memory consolidation. ↗
▶ Ep 21 · 44:25
quote But if you raise your hand and I call on you and your heart starts beating and you start flushing and you get it wrong, you won't forget the right answer. If you get it right, you'll remember it because you were happy about it. There was an investment there. ↗
Jeffrey's statements about Gastroparesis 61 statements

Open the Gastroparesis collection →

The invention of the PEG tube with Dr. Jeffrey Ponsky

▶ Ep 6 · 2:43
quote I was told I couldn't do it because I was a surgical resident, and that piqued my interest ↗
▶ Ep 6 · 3:02
quote I came back after that training and I was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments ↗
▶ Ep 6 · 3:27
clinical In 1974-1975, there were no pediatric gastroenterologists, and Ponsky performed endoscopy on children, young adults, and neonates with GI problems using his personally owned scope. ↗
▶ Ep 6 · 4:33
clinical During neonatal endoscopy, the room would light up because babies were so thin; when pediatric surgeon Michael Gower pushed on the transilluminated light with his finger, an indentation was visible endoscopically. ↗
▶ Ep 6 · 4:42
quote Michael would push on the light with his finger, and I'd be scoping and I would see an indentation. And we realized we got together and said, you know, maybe we could do something with this. ↗
▶ Ep 6 · 4:59
clinical The first PEG tubes were constructed from OR gastrostomy tubes (small Pezzer catheters) with sutures threaded through the end and passed through an IV catheter (medicut) to create a dilator tip. ↗
▶ Ep 6 · 5:42
clinical The first five PEG procedures in May 1979 were performed in neonates with severe psychomotor retardation who were brain dead, fed by nasogastric tubes, had no chance of recovery, and were being sent for open gastrostomy before long-term nursing facility placement. ↗
▶ Ep 6 · 6:15
quote we have to do a major laparotomy on these babies, uh, but we have an idea for performing this, uh, by a new technique. Uh, we don't have any idea if it'll work. We think it will, it's pretty simple, but if it doesn't, we will do the laparotomy right there and then and complete the gastrostomy ↗
▶ Ep 6 · 6:25
clinical Informed consent for the first PEG cases consisted of telling mothers that if the new technique failed, immediate laparotomy and open gastrostomy would be performed. ↗
▶ Ep 6 · 6:37
quote That was the informed consent at that time. ↗
▶ Ep 6 · 6:42
clinical The first PEG procedures succeeded easily within a few minutes. ↗
▶ Ep 6 · 6:47
clinical After the initial five neonatal cases, Ponsky moved to Mount Sinai Medical Center and began performing PEG in adult stroke patients with similar neurologic prognosis who needed feeding access. ↗
▶ Ep 6 · 7:13
clinical Laboratory studies on PEG tract formation, tube dwell time before safe replacement, and leakage risk were conducted after clinical implementation—the reverse of typical research-then-clinical sequence. ↗
▶ Ep 6 · 7:28
clinical John Mellinger, who later worked at the American Board of Surgery, conducted original research on PEG tract formation. ↗
▶ Ep 6 · 7:44
quote it was sort of the reverse of what you would do now by going to the laboratory first and then And then to the operating room. ↗
▶ Ep 6 · 8:18
quote We didn't have IRBs in those days. ↗
▶ Ep 6 · 8:39
clinical Multiple medical device companies refused to manufacture the PEG tube initially, believing nobody would use it. ↗
▶ Ep 6 · 8:54
clinical A small company in Mentor, Ohio eventually manufactured the PEG tube exactly as designed by Ponsky and Gower. ↗
▶ Ep 6 · 9:06
opinion Ponsky and Gower never patented the PEG tube; they were more interested in publication than patents and wanted to disseminate the technique. ↗
▶ Ep 6 · 9:06
quote we never even thought about patenting the tube. It wasn't even on our mind. ↗
▶ Ep 6 · 9:18
quote We wanted to get papers out of it. We wanted to make a contribution to literature. We were more interested in publication than patents ↗
▶ Ep 6 · 9:39
clinical PEG tube complications included rare colonic perforation when the tube traversed the colon en route to the stomach, which still occurs rarely today. ↗
▶ Ep 6 · 9:51
clinical Exit-site infection was a major early PEG complication. ↗
▶ Ep 6 · 10:24
clinical PEG tubes evolved from multi-piece rubber construction to one-piece silicone, but have had very few modifications in the last few years and have become a commodity product purchased by hospitals at the lowest price. ↗
▶ Ep 6 · 10:50
clinical The PEG technique has remained very much the same as the original with only a few modifications. ↗
▶ Ep 6 · 11:19
clinical Ponsky and the manufacturing company conducted dozens of animal experiments to determine tube removal pressure, tip retention, and optimal tube size for FDA approval. ↗
▶ Ep 6 · 12:09
quote I said, wow, look at this. What else can we do with this thing? ↗
▶ Ep 6 · 12:13
clinical The PEG tube was the first and only time any instrument or needle was thrust through the abdominal wall into the GI tract and left in place. ↗
▶ Ep 6 · 12:13
quote the peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract. ↗
▶ Ep 6 · 12:55
clinical In 1975, Ponsky developed and published endoscopic tattooing using India ink injected alongside polypectomy sites to mark the location for potential surgical resection if cancer was found; the technique remains in use today. ↗
▶ Ep 6 · 13:38
quote there was a lot of low hanging fruit then we could do things that seemed logical, and that's the fun of a new area. ↗
▶ Ep 6 · 13:56
quote everybody thinks that everybody's been, everything's been discovered already, that's not true. ↗
▶ Ep 6 · 15:31
clinical In the late 1970s, surgical residents were on call every other night (36 hours on, 12 hours off) for five years of training. ↗
▶ Ep 6 · 15:49
quote I wanna have an elective that's a little bit easier. ↗
▶ Ep 6 · 15:58
quote I said, wow, that would be a great way to blow up 3 months. I won't have to take night off. This will be easier. That was an accident. ↗
▶ Ep 6 · 17:07
quote when you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it. ↗
▶ Ep 6 · 17:35
clinical In the mid-1970s, the predominant American endoscope was the ACMI (American Cystoscope Makers Incorporated) with a joystick control, approximately 1 cm diameter, with image quality like looking through ground glass. ↗
▶ Ep 6 · 18:00
quote it was like looking through ground glass. ↗
▶ Ep 6 · 18:03
clinical Japanese companies (Mashida and Olympus in the US) produced fiber-optic endoscopes with crystal-clear optics that were markedly superior to American models. ↗
▶ Ep 6 · 18:15
quote It was crystal clear. It was like you were just right there. ↗
▶ Ep 6 · 18:21
quote I bought the best instrument. ↗
▶ Ep 6 · 18:26
clinical 1970s fiber-optic endoscopes transmitted light via fiber bundles to the lumen and returned images to the eyepiece; photography required clipping a camera to the eyepiece for film-strip images. ↗
▶ Ep 6 · 18:51
clinical Teaching attachments for 1970s endoscopes consisted of a wire-connected second eyepiece that provided a dim image for trainees in darkened rooms. ↗
▶ Ep 6 · 19:06
clinical Around 1980, video chip technology placed a camera at the endoscope tip instead of using fiber-optic image transmission, displaying images on large monitors—the technology used in current endoscopes. ↗
▶ Ep 6 · 19:36
clinical In the late 1970s, neonates could tolerate endoscopes approximately 9 millimeters wide, which was the limit for safe use. ↗
▶ Ep 6 · 19:57
clinical The original PEG procedure was performed with an adult endoscope. ↗
▶ Ep 6 · 20:07
quote I would almost not let anyone touch it except me ↗
▶ Ep 6 · 20:56
clinical In the 1970s, endoscopes were cleaned between procedures using only green soap; high-level disinfection and sterilization protocols did not yet exist. ↗
▶ Ep 6 · 21:45
clinical The PEG tube received FDA 510(k) approval as a modification of existing gastrostomy tubes used for similar purposes, which is easier than approval for entirely novel devices. ↗
▶ Ep 6 · 22:17
clinical PEG indications expanded beyond feeding to include gastric decompression in gastroparesis or obstruction (including carcinomatosis), delivery of unpalatable feedings, and treatment of gastric volvulus. ↗
▶ Ep 6 · 23:00
clinical The PEG technique was adapted for colonic applications including sigmoid volvulus fixation and Ogilvie syndrome decompression, with multiple PEGs used for sigmoid volvulus. ↗
▶ Ep 6 · 23:30
quote I like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation. That's what we think of as surgeons. ↗
▶ Ep 6 · 23:56
opinion Many endoscopic procedures developed by surgeons, including PEG, were extensions of surgical operations already performed via laparotomy. ↗
▶ Ep 6 · 25:32
clinical Gastroenterologists rapidly adopted PEG as a therapeutic procedure they could easily accomplish, driving widespread dissemination. ↗
▶ Ep 6 · 25:56
clinical Surgeons were slower to adopt PEG initially because they were not performing as much therapeutic endoscopy at that time, but they did not offer significant resistance. ↗
▶ Ep 6 · 26:40
clinical A properly performed PEG procedure takes under 5 minutes when done carefully by an experienced operator. ↗
▶ Ep 6 · 26:47
clinical Current PEG procedures still require patient sedation or anesthesia and constitute an intervention. ↗
▶ Ep 6 · 26:58
quote I want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local ↗
▶ Ep 6 · 27:31
quote don't stop dreaming and stop thinking. ↗
▶ Ep 6 · 27:43
opinion Radiologists perform gastrostomy tube placement using ultrasound guidance, though Ponsky does not prefer the tubes they use. ↗
▶ Ep 6 · 32:57
quote you should always uh take a chance. Now, you shouldn't take a chance with patients' lives, but you should take a chance on developing new ideas and new procedures and new instruments. ↗
Jeffrey's statements about Inguinal Hernia 2 statements

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Inguinal Hernia: Adult

▶ Ep 6 · 0:54
quote I say the word simple because it's anything but simple. This is a topic which has challenged surgeons for a century, and every generation really believes that they have the correct answer to hernia repair. ↗
▶ Ep 6 · 0:54
quote I say the word simple because it's anything but simple. This is a topic which has challenged surgeons for a century, and every generation really believes that they have the correct answer to hernia repair. ↗
Jeffrey's statements about Low Cardiac Output 2 statements

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Inguinal Hernia: Adult

▶ Ep 1 · 0:54
quote I say the word simple because it's anything but simple. This is a topic which has challenged surgeons for a century, and every generation really believes that they have the correct answer to hernia repair. ↗
▶ Ep 1 · 0:54
quote I say the word simple because it's anything but simple. This is a topic which has challenged surgeons for a century, and every generation really believes that they have the correct answer to hernia repair. ↗
Jeffrey's statements about Obesity 32 statements

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StayCurrent Forums - Obesity in Children

▶ Ep 15 · 1:18
epidemiological Numbers from 2017 show approximately 14.5 million children in the United States are struggling with obesity. ↗
▶ Ep 15 · 1:18
epidemiological Big increases in pediatric obesity have been seen with COVID. ↗
▶ Ep 15 · 2:15
clinical Epigenetic changes are thought to be causing higher levels of obesity. ↗
▶ Ep 15 · 2:15
clinical Obesity is a disease, and once weight is gained, the body fights to keep it on. ↗
▶ Ep 15 · 2:15
quote if it was just calories in and calories out, I wouldn't have a job. And it wouldn't be a multi-billion dollar industry as well, right? It's just not that simple. ↗
▶ Ep 15 · 3:06
quote The more you talk about weight with your kids, the more likely they are to develop more issues and actually eating disorders in the future. ↗
▶ Ep 15 · 3:06
clinical Talking about weight with children increases the likelihood they will develop eating disorders in the future. ↗
▶ Ep 15 · 3:25
clinical Management should focus on health and the whole family doing healthy habits together rather than discussing weight. ↗
▶ Ep 15 · 3:25
epidemiological There has been a tremendous decrease in physical activity among children. ↗
▶ Ep 15 · 3:25
clinical Stopping sugar drinks and sodas is recommended because these are easy calories to eliminate and are harmful to the body and liver. ↗
▶ Ep 15 · 4:46
opinion Bariatric surgery is not a last resort but a viable treatment option that should be offered to children. ↗
▶ Ep 15 · 4:46
clinical Everybody gets lifestyle changes regardless of treatment path. ↗
▶ Ep 15 · 4:46
quote bariatric surgery is just as good if you're black or if you're white or if you're Asian. ↗
▶ Ep 15 · 4:46
quote bariatric surgery is not a last resort. It's not that it's it's something we need to offer our kids because it's a viable option. ↗
▶ Ep 15 · 4:46
clinical There is an increase in the use of medications for pediatric obesity, with off-label use until age 18 supported by research. ↗
▶ Ep 15 · 4:46
clinical Bariatric surgery works well across races and cultures, being equally effective for Black, White, and Asian patients. ↗
▶ Ep 15 · 5:40
clinical Some GLP-1 inhibitors have been approved for ages 12 to 18. ↗
▶ Ep 15 · 5:40
clinical Medications used for pediatric obesity include GLP-1 inhibitors, phentermine, Wellbutrin, and Topamax, all used off-label. ↗
▶ Ep 15 · 6:31
clinical Wellbutrin has a black box warning because it is an antidepressant, but it can help as an activator giving patients a boost. ↗
▶ Ep 15 · 8:07
epidemiological Pediatric bariatric surgery patients typically have BMIs closer to 50 at the time of surgery. ↗
▶ Ep 15 · 8:07
clinical Bariatric surgery produces approximately a 25 to 35% decrease in BMI. ↗
▶ Ep 15 · 8:07
clinical Bariatric surgery in pediatrics is offered late, and starting at BMIs of 50 or 60 limits how far patients can expect to go with surgery. ↗
▶ Ep 15 · 8:07
epidemiological Adult bariatric surgery patients typically have BMIs in the low 40s at the time of surgery. ↗
▶ Ep 15 · 8:52
quote these are kids and the their frontal lobe isn't developed. So therefore their ability to plan is really not there. ↗
▶ Ep 15 · 8:52
clinical Children's frontal lobes are not fully developed, limiting their ability to plan, which requires working with their developmental level to build skills for post-operative success. ↗
▶ Ep 15 · 10:10
clinical Most pediatric bariatric surgery patients have not been disappointed in their weight loss, with any weight loss making them feel good, stronger, and happier. ↗
▶ Ep 15 · 10:10
quote my favorite visit is that first post-op visit where they're wearing new clothes or they're putting on makeup or they just have that new zest for for life. ↗
▶ Ep 15 · 11:32
clinical The sleeve gastrectomy decreases hunger after surgery because many ghrelin cells are removed. ↗
▶ Ep 15 · 12:51
clinical If sleeve gastrectomy does not work, it can be converted to a gastric bypass. ↗
▶ Ep 15 · 12:51
epidemiological Almost all adolescent bariatric surgeries are sleeve gastrectomies. ↗
▶ Ep 15 · 12:51
clinical After gastric bypass, the duodenum and gastric remnant cannot be visualized, which is a concern in young people with long life expectancy. ↗
▶ Ep 15 · 15:16
clinical Currently, zero pediatric sleeve gastrectomy patients have required conversion to Roux-en-Y gastric bypass, though this may be seen by adult surgeons since the average patient age is 17. ↗
Jeffrey's statements about Pancreatitis 93 statements

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Gallstone Disease

▶ Ep 11 · 1:53
clinical Biliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative. ↗
▶ Ep 11 · 1:53
clinical Biliary dyskinesia is diagnosed with a HIDA scan showing ejection fraction less than 35% after CCK administration, when all other tests are negative. ↗
▶ Ep 11 · 5:00
clinical Modern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks. ↗
▶ Ep 11 · 5:00
clinical Modern practice favors early cholecystectomy within the first week for acute cholecystitis, rather than the older approach of cooling down for six weeks. ↗
▶ Ep 11 · 5:40
clinical For stable acute cholecystitis without peritonitis, it is reasonable to wait until the next operating day (e.g., Monday if presenting Saturday) rather than operating emergently. ↗
▶ Ep 11 · 5:40
clinical For stable acute cholecystitis without peritonitis, it is reasonable to wait until the next operating day (e.g., Monday if presenting Saturday) rather than operating emergently. ↗
▶ Ep 11 · 6:10
clinical There is no evidence that prophylactic antibiotics help in acute cholecystitis management. ↗
▶ Ep 11 · 6:10
clinical There is no evidence that prophylactic antibiotics help in acute cholecystitis management. ↗
▶ Ep 11 · 12:12
clinical The sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas. ↗
▶ Ep 11 · 12:12
clinical The sucker is a great tool for blunt dissection during difficult cholecystectomy; hydrodissection (injecting water between tissue planes) helps in tough areas. ↗
▶ Ep 11 · 12:40
clinical After isolating the cystic duct-gallbladder junction, turning the hook cautery toward the gallbladder and lifting while cauterizing gains an additional half-centimeter of cystic duct length. ↗
▶ Ep 11 · 12:40
clinical After isolating the cystic duct-gallbladder junction, turning the hook cautery toward the gallbladder and lifting while cauterizing gains an additional half-centimeter of cystic duct length. ↗
▶ Ep 11 · 13:02
opinion Easy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed. ↗
▶ Ep 11 · 13:02
quote Easy gallbladders are the ones where you can make the bad mistakes. There can be accessory cystic ducts, there can be problems with the cystic artery that you didn't realize, an anterior and posterior one, and you have to be careful. So it's real easy, make yourself slow down. You know you're going to go slow on a hard one. Go slow on an easy one. ↗
▶ Ep 11 · 13:02
opinion Easy gallbladders are dangerous because surgeons become complacent; accessory cystic ducts and vascular variants can be missed. ↗
▶ Ep 11 · 13:02
quote Easy gallbladders are the ones where you can make the bad mistakes. There can be accessory cystic ducts, there can be problems with the cystic artery that you didn't realize, an anterior and posterior one, and you have to be careful. So it's real easy, make yourself slow down. You know you're going to go slow on a hard one. Go slow on an easy one. ↗
▶ Ep 11 · 14:50
clinical Routine intraoperative cholangiography is debated; some institutions do it in every case for teaching and to improve transcystic exploration skills, while selective use based on risk factors (pancreatitis history, jaundice, dilated duct) is also acceptable. ↗
▶ Ep 11 · 14:50
clinical Routine intraoperative cholangiography is debated; some institutions do it in every case for teaching and to improve transcystic exploration skills, while selective use based on risk factors (pancreatitis history, jaundice, dilated duct) is also acceptable. ↗
▶ Ep 11 · 18:33
clinical When contrast on cholangiogram flows only distally into the duodenum, pressing on the papilla with the laparoscope under fluoroscopy forces contrast proximally, avoiding the need for morphine to induce sphincter spasm (technique taught by Michelle Gagné). ↗
▶ Ep 11 · 18:33
clinical When contrast on cholangiogram flows only distally into the duodenum, pressing on the papilla with the laparoscope under fluoroscopy forces contrast proximally, avoiding the need for morphine to induce sphincter spasm (technique taught by Michelle Gagné). ↗
▶ Ep 11 · 19:00
clinical Intraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy. ↗
▶ Ep 11 · 19:00
clinical Intraoperative administration of 30mg Toradol (age-adjusted in children) before the patient wakes facilitates same-day discharge after cholecystectomy. ↗
▶ Ep 11 · 20:30
quote If you have a patient that you did a lap choleon, and they call you because they're having pain, something's wrong. Lap choleys don't have pain if everything went well. Now, I may be wrong in 1% of cases, but not many. The patient calls you, the mother calls you, or anybody calls you, says, you know, he's a little nausea, he's not eating well, a little bloated, and he's having pain. It's three days later. Come into the emergency room. Stat. Because in my mind, that's a bile leak, and even, God forbid, a common duct injury until proven otherwise. ↗
▶ Ep 11 · 20:30
clinical Any patient with pain 3-5 days after laparoscopic cholecystectomy should be assumed to have a bile leak or bile duct injury until proven otherwise; laparoscopic cholecystectomies do not cause pain if everything went well. ↗
▶ Ep 11 · 20:30
quote If you have a patient that you did a lap choleon, and they call you because they're having pain, something's wrong. Lap choleys don't have pain if everything went well. Now, I may be wrong in 1% of cases, but not many. The patient calls you, the mother calls you, or anybody calls you, says, you know, he's a little nausea, he's not eating well, a little bloated, and he's having pain. It's three days later. Come into the emergency room. Stat. Because in my mind, that's a bile leak, and even, God forbid, a common duct injury until proven otherwise. ↗
▶ Ep 11 · 20:30
clinical Any patient with pain 3-5 days after laparoscopic cholecystectomy should be assumed to have a bile leak or bile duct injury until proven otherwise; laparoscopic cholecystectomies do not cause pain if everything went well. ↗
▶ Ep 11 · 21:11
clinical For suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP. ↗
▶ Ep 11 · 21:11
clinical For suspected postoperative bile leak, obtain CT or ultrasound to identify fluid collections; if present, aspirate immediately—if bile is present, proceed to ERCP. ↗
▶ Ep 11 · 21:32
opinion HIDA scans are useful to confirm normal biliary drainage when postoperative pain occurs without fluid collection, but are less useful than CT for detecting bile leaks. ↗
▶ Ep 11 · 21:32
opinion HIDA scans are useful to confirm normal biliary drainage when postoperative pain occurs without fluid collection, but are less useful than CT for detecting bile leaks. ↗
▶ Ep 11 · 22:37
clinical For bile leaks (typically cystic duct), ERCP with sphincterotomy and short stent (10 French, 5cm) decompresses the biliary system and stops drainage; stent is removed at 3-6 weeks. ↗
▶ Ep 11 · 22:37
clinical For bile leaks (typically cystic duct), ERCP with sphincterotomy and short stent (10 French, 5cm) decompresses the biliary system and stops drainage; stent is removed at 3-6 weeks. ↗
▶ Ep 11 · 23:41
clinical Biliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative. ↗
▶ Ep 11 · 23:41
clinical Biliary dyskinesia with ejection fraction less than 35% is an indication for cholecystectomy when all other GI workup is negative. ↗
▶ Ep 11 · 24:11
clinical Gallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla. ↗
▶ Ep 11 · 24:11
clinical Gallstone pancreatitis is caused by small stones creating transient obstruction of both bile and pancreatic ducts while passing through the papilla. ↗
▶ Ep 11 · 24:40
clinical In the old practice, all patients with gallstone pancreatitis received ERCP on presentation, but two-thirds had normal ERCPs because the stone had already passed. ↗
▶ Ep 11 · 24:40
quote The rule is, in the old days, everybody got ERCP the day they came in. Hydrate them, make them NPO, watch them in the hospital, and don't get the ERCP on the first day because when we did that, we found that two-thirds of the patients that we did the ERCPs on had normal ERCPs. ↗
▶ Ep 11 · 24:40
quote The rule is, in the old days, everybody got ERCP the day they came in. Hydrate them, make them NPO, watch them in the hospital, and don't get the ERCP on the first day because when we did that, we found that two-thirds of the patients that we did the ERCPs on had normal ERCPs. ↗
▶ Ep 11 · 24:40
clinical In the old practice, all patients with gallstone pancreatitis received ERCP on presentation, but two-thirds had normal ERCPs because the stone had already passed. ↗
▶ Ep 11 · 25:10
clinical Current management of gallstone pancreatitis: admit, hydrate, NPO, observe overnight and check amylase/lipase trend. If improving, proceed to cholecystectomy during that admission. If worsening or jaundice persists, perform ERCP with sphincterotomy. ↗
▶ Ep 11 · 25:10
clinical Current management of gallstone pancreatitis: admit, hydrate, NPO, observe overnight and check amylase/lipase trend. If improving, proceed to cholecystectomy during that admission. If worsening or jaundice persists, perform ERCP with sphincterotomy. ↗
▶ Ep 11 · 26:27
opinion The choice between preoperative ERCP versus intraoperative common duct exploration depends on local resources, surgeon comfort with laparoscopic ductal techniques, and availability of fluoroscopy and choledocoscopy. ↗
▶ Ep 11 · 26:27
opinion The choice between preoperative ERCP versus intraoperative common duct exploration depends on local resources, surgeon comfort with laparoscopic ductal techniques, and availability of fluoroscopy and choledocoscopy. ↗
▶ Ep 11 · 28:33
clinical Some experts (George Bursey, Joe Peatland) advocate taking patients with persistent common duct stones directly to the operating room for intraoperative cholangiogram and transcystic or laparoscopic common duct exploration, with postoperative ERCP only if unsuccessful. ↗
▶ Ep 11 · 30:14
clinical For intraoperative common duct stone clearance, after cholangiogram shows a stone (meniscus sign), give 1 amp (1mg) glucagon IV, wait 1-2 minutes, flush with saline, and repeat cholangiogram. ↗
▶ Ep 11 · 30:14
clinical For intraoperative common duct stone clearance, after cholangiogram shows a stone (meniscus sign), give 1 amp (1mg) glucagon IV, wait 1-2 minutes, flush with saline, and repeat cholangiogram. ↗
▶ Ep 11 · 30:56
clinical If glucagon fails to clear the stone, pass a soft-tip wire through the cystic duct under fluoroscopy into the duodenum to attempt to dislodge it; never push against resistance. ↗
▶ Ep 11 · 30:56
clinical If glucagon fails to clear the stone, pass a soft-tip wire through the cystic duct under fluoroscopy into the duodenum to attempt to dislodge it; never push against resistance. ↗
▶ Ep 11 · 31:35
clinical A Dormia basket can be passed closed into the duodenum under fluoroscopy, opened slightly, and pulled back with jiggling to catch stones; alternatively, a #5 Fogarty catheter (vascular Fogarty works) can be inflated in the duodenum, pulled to the papilla, deflated slightly, re-inflated and pulled back. ↗
▶ Ep 11 · 31:35
clinical A Dormia basket can be passed closed into the duodenum under fluoroscopy, opened slightly, and pulled back with jiggling to catch stones; alternatively, a #5 Fogarty catheter (vascular Fogarty works) can be inflated in the duodenum, pulled to the papilla, deflated slightly, re-inflated and pulled back. ↗
▶ Ep 11 · 32:44
clinical Modern choledocoscopes are less than 3mm diameter and can be passed through the cystic duct (sometimes requiring balloon dilation) for direct stone visualization and extraction with Dormia basket or balloon. ↗
▶ Ep 11 · 32:44
clinical Modern choledocoscopes are less than 3mm diameter and can be passed through the cystic duct (sometimes requiring balloon dilation) for direct stone visualization and extraction with Dormia basket or balloon. ↗
▶ Ep 11 · 33:27
clinical After transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties. ↗
▶ Ep 11 · 33:27
clinical After transcystic common duct exploration, place endoloops on the cystic duct stump because prolonged obstruction can blow off simple ties. ↗
▶ Ep 11 · 34:56
clinical Laparoscopic common bile duct exploration via choledocotomy should only be performed in dilated ducts (>1-1.5cm, ideally 2cm) to avoid stricture risk; small-caliber ducts with stones should be managed with ERCP. ↗
▶ Ep 11 · 34:56
clinical Laparoscopic common bile duct exploration via choledocotomy should only be performed in dilated ducts (>1-1.5cm, ideally 2cm) to avoid stricture risk; small-caliber ducts with stones should be managed with ERCP. ↗
▶ Ep 11 · 35:30
clinical For laparoscopic choledocotomy, do not divide the cystic duct—use the gallbladder for lateral retraction while dissecting down to expose the anterior common duct surface. ↗
▶ Ep 11 · 35:30
clinical For laparoscopic choledocotomy, do not divide the cystic duct—use the gallbladder for lateral retraction while dissecting down to expose the anterior common duct surface. ↗
▶ Ep 11 · 37:40
clinical T-tube preparation for choledocotomy closure: cut to 1 inch on each side of the T, bevel the edges, remove half the back wall to facilitate insertion and later removal. ↗
▶ Ep 11 · 37:40
clinical T-tube preparation for choledocotomy closure: cut to 1 inch on each side of the T, bevel the edges, remove half the back wall to facilitate insertion and later removal. ↗
▶ Ep 11 · 38:50
clinical T-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks. ↗
▶ Ep 11 · 38:50
clinical T-tube cholangiogram is performed at 10 days post-choledocotomy; if clear, the T-tube is removed at 2 weeks. ↗
▶ Ep 11 · 39:27
clinical For severe pancreatitis with large phlegmon in the pancreatic head, obtain CT and consider waiting 6 weeks before cholecystectomy to allow inflammation to resolve. ↗
▶ Ep 11 · 39:27
clinical For severe pancreatitis with large phlegmon in the pancreatic head, obtain CT and consider waiting 6 weeks before cholecystectomy to allow inflammation to resolve. ↗
▶ Ep 11 · 40:00
clinical For patients with multiple stones extending up both hepatic ducts in a very dilated common duct, or stone-formers like sickle cell patients, consider choledochoduodenostomy (2cm anastomosis) as a drainage procedure to allow future stones to pass. ↗
▶ Ep 11 · 40:00
clinical For patients with multiple stones extending up both hepatic ducts in a very dilated common duct, or stone-formers like sickle cell patients, consider choledochoduodenostomy (2cm anastomosis) as a drainage procedure to allow future stones to pass. ↗
▶ Ep 11 · 41:04
clinical Percutaneous cholecystostomy can temporize severe acute cholecystitis in high-risk patients or those with large phlegmon, allowing interval cholecystectomy at 6 weeks, but requires normal clotting studies. ↗
▶ Ep 11 · 41:04
clinical Percutaneous cholecystostomy can temporize severe acute cholecystitis in high-risk patients or those with large phlegmon, allowing interval cholecystectomy at 6 weeks, but requires normal clotting studies. ↗
▶ Ep 11 · 41:47
clinical In cases where anatomy is unrecognizable intraoperatively, subtotal cholecystectomy is acceptable: remove the anterior wall or fundus, cauterize the remaining mucosa on the back wall with bovie to prevent mucocele, place drains, and accept a controlled leak. ↗
▶ Ep 11 · 41:47
clinical In cases where anatomy is unrecognizable intraoperatively, subtotal cholecystectomy is acceptable: remove the anterior wall or fundus, cauterize the remaining mucosa on the back wall with bovie to prevent mucocele, place drains, and accept a controlled leak. ↗
▶ Ep 11 · 42:29
clinical Common bile duct injuries typically occur during 'easy' cases when surgeons become complacent and fail to maintain vigilance. ↗
▶ Ep 11 · 42:29
clinical Common bile duct injuries typically occur during 'easy' cases when surgeons become complacent and fail to maintain vigilance. ↗
▶ Ep 11 · 43:00
clinical The common duct can come up to the gallbladder and take a bend like a knee, appearing identical to the cystic duct; only continued dissection reveals the true 2-3mm cystic duct coming off the 'knee.' ↗
▶ Ep 11 · 43:00
clinical The common duct can come up to the gallbladder and take a bend like a knee, appearing identical to the cystic duct; only continued dissection reveals the true 2-3mm cystic duct coming off the 'knee.' ↗
▶ Ep 11 · 43:29
clinical Being able to pass an instrument around a structure does not prove it is the cystic duct—the common bile duct can be encircled and mistakenly used for retraction. ↗
▶ Ep 11 · 43:29
clinical Being able to pass an instrument around a structure does not prove it is the cystic duct—the common bile duct can be encircled and mistakenly used for retraction. ↗
▶ Ep 11 · 44:00
quote If you're going to do biliary surgery, this could happen to anyone. Know that. It's not an incrimination of you. Stop. Suck it out. Take a few breaths and if you have another partner, call them in. ↗
▶ Ep 11 · 44:00
clinical If common bile duct injury is recognized intraoperatively: STOP immediately, call for help, and assess. If shaken or inexperienced with hepaticojejunostomy, do not attempt repair. ↗
▶ Ep 11 · 44:00
quote If you're going to do biliary surgery, this could happen to anyone. Know that. It's not an incrimination of you. Stop. Suck it out. Take a few breaths and if you have another partner, call them in. ↗
▶ Ep 11 · 44:00
clinical If common bile duct injury is recognized intraoperatively: STOP immediately, call for help, and assess. If shaken or inexperienced with hepaticojejunostomy, do not attempt repair. ↗
▶ Ep 11 · 44:20
clinical In most bile duct injury cases, the primary injury is compounded by the attempted repair. ↗
▶ Ep 11 · 44:20
quote What happens in most of these cases is the primary injury is compounded by the attempted repair. ↗
▶ Ep 11 · 44:20
quote What happens in most of these cases is the primary injury is compounded by the attempted repair. ↗
▶ Ep 11 · 44:20
clinical In most bile duct injury cases, the primary injury is compounded by the attempted repair. ↗
▶ Ep 11 · 44:37
clinical Primary end-to-end repair of transected common bile duct is almost always fraught with failure; most common duct injuries (except small lateral injuries) are best treated with hepaticojejunostomy. ↗
▶ Ep 11 · 44:37
quote A primary end-to-end repair of the common bile duct is almost always fraught with failure. Most often, a common duct injury, unless it's just a lateral injury, is best treated with a hepatic oj genostomy. ↗
▶ Ep 11 · 44:37
quote A primary end-to-end repair of the common bile duct is almost always fraught with failure. Most often, a common duct injury, unless it's just a lateral injury, is best treated with a hepatic oj genostomy. ↗
▶ Ep 11 · 44:37
clinical Primary end-to-end repair of transected common bile duct is almost always fraught with failure; most common duct injuries (except small lateral injuries) are best treated with hepaticojejunostomy. ↗
▶ Ep 11 · 44:56
clinical For small lateral common duct injuries, place a small T-tube rather than primary suture closure, as suture alone will leak. ↗
▶ Ep 11 · 44:56
clinical For small lateral common duct injuries, place a small T-tube rather than primary suture closure, as suture alone will leak. ↗
▶ Ep 11 · 45:37
clinical For complete common duct transection, leave everything alone, place multiple drains, do not place ties or tubes that will compromise remaining duct length for the hepatobiliary surgeon, and transfer the patient. ↗
▶ Ep 11 · 45:37
clinical For complete common duct transection, leave everything alone, place multiple drains, do not place ties or tubes that will compromise remaining duct length for the hepatobiliary surgeon, and transfer the patient. ↗
Jeffrey's statements about Pediatric Obesity 32 statements

Open the Pediatric Obesity collection →

StayCurrent Forums - Obesity in Children

▶ Ep 9 · 1:18
epidemiological Numbers from 2017 show approximately 14.5 million children in the United States are struggling with obesity. ↗
▶ Ep 9 · 1:18
epidemiological Big increases in pediatric obesity have been seen with COVID. ↗
▶ Ep 9 · 2:15
quote if it was just calories in and calories out, I wouldn't have a job. And it wouldn't be a multi-billion dollar industry as well, right? It's just not that simple. ↗
▶ Ep 9 · 2:15
clinical Obesity is a disease, and once weight is gained, the body fights to keep it on. ↗
▶ Ep 9 · 2:15
clinical Epigenetic changes are thought to be causing higher levels of obesity. ↗
▶ Ep 9 · 3:06
clinical Talking about weight with children increases the likelihood they will develop eating disorders in the future. ↗
▶ Ep 9 · 3:06
quote The more you talk about weight with your kids, the more likely they are to develop more issues and actually eating disorders in the future. ↗
▶ Ep 9 · 3:25
epidemiological There has been a tremendous decrease in physical activity among children. ↗
▶ Ep 9 · 3:25
clinical Stopping sugar drinks and sodas is recommended because these are easy calories to eliminate and are harmful to the body and liver. ↗
▶ Ep 9 · 3:25
clinical Management should focus on health and the whole family doing healthy habits together rather than discussing weight. ↗
▶ Ep 9 · 4:46
clinical Bariatric surgery works well across races and cultures, being equally effective for Black, White, and Asian patients. ↗
▶ Ep 9 · 4:46
quote bariatric surgery is just as good if you're black or if you're white or if you're Asian. ↗
▶ Ep 9 · 4:46
clinical Everybody gets lifestyle changes regardless of treatment path. ↗
▶ Ep 9 · 4:46
clinical There is an increase in the use of medications for pediatric obesity, with off-label use until age 18 supported by research. ↗
▶ Ep 9 · 4:46
opinion Bariatric surgery is not a last resort but a viable treatment option that should be offered to children. ↗
▶ Ep 9 · 4:46
quote bariatric surgery is not a last resort. It's not that it's it's something we need to offer our kids because it's a viable option. ↗
▶ Ep 9 · 5:40
clinical Medications used for pediatric obesity include GLP-1 inhibitors, phentermine, Wellbutrin, and Topamax, all used off-label. ↗
▶ Ep 9 · 5:40
clinical Some GLP-1 inhibitors have been approved for ages 12 to 18. ↗
▶ Ep 9 · 6:31
clinical Wellbutrin has a black box warning because it is an antidepressant, but it can help as an activator giving patients a boost. ↗
▶ Ep 9 · 8:07
clinical Bariatric surgery in pediatrics is offered late, and starting at BMIs of 50 or 60 limits how far patients can expect to go with surgery. ↗
▶ Ep 9 · 8:07
epidemiological Adult bariatric surgery patients typically have BMIs in the low 40s at the time of surgery. ↗
▶ Ep 9 · 8:07
epidemiological Pediatric bariatric surgery patients typically have BMIs closer to 50 at the time of surgery. ↗
▶ Ep 9 · 8:07
clinical Bariatric surgery produces approximately a 25 to 35% decrease in BMI. ↗
▶ Ep 9 · 8:52
clinical Children's frontal lobes are not fully developed, limiting their ability to plan, which requires working with their developmental level to build skills for post-operative success. ↗
▶ Ep 9 · 8:52
quote these are kids and the their frontal lobe isn't developed. So therefore their ability to plan is really not there. ↗
▶ Ep 9 · 10:10
quote my favorite visit is that first post-op visit where they're wearing new clothes or they're putting on makeup or they just have that new zest for for life. ↗
▶ Ep 9 · 10:10
clinical Most pediatric bariatric surgery patients have not been disappointed in their weight loss, with any weight loss making them feel good, stronger, and happier. ↗
▶ Ep 9 · 11:32
clinical The sleeve gastrectomy decreases hunger after surgery because many ghrelin cells are removed. ↗
▶ Ep 9 · 12:51
epidemiological Almost all adolescent bariatric surgeries are sleeve gastrectomies. ↗
▶ Ep 9 · 12:51
clinical If sleeve gastrectomy does not work, it can be converted to a gastric bypass. ↗
▶ Ep 9 · 12:51
clinical After gastric bypass, the duodenum and gastric remnant cannot be visualized, which is a concern in young people with long life expectancy. ↗
▶ Ep 9 · 15:16
clinical Currently, zero pediatric sleeve gastrectomy patients have required conversion to Roux-en-Y gastric bypass, though this may be seen by adult surgeons since the average patient age is 17. ↗
Jeffrey's statements about Psychomotor Retardation 161 statements

Open the Psychomotor Retardation collection →

SAGES Stories Episode 11 – Jeff Ponsky, MD

▶ Ep 1 · 6:49
clinical Ponsky had a 2.027 GPA graduating from Cleveland Heights High School and his college counselor recommended trade school instead of college. ↗
▶ Ep 1 · 9:01
quote Look, I'm gonna do this as best I can do. I don't know what I'm gonna do. All I know is that I'm gonna work my butt off, and I'm not gonna screw around and I'm not gonna party cause I've done that my whole life and now I was just gonna study. ↗
▶ Ep 1 · 9:17
opinion Ponsky's transformation in college came from memorizing everything and studying constantly, discovering he had an exceptional memory that allowed him to 'eat the book and spit it out.' ↗
▶ Ep 1 · 21:12
clinical Walter Pore taught pinch grafting technique at Metro Hospital, where students would inject local anesthesia, harvest small 'postage stamp' skin grafts from the thigh, and apply them to debrided bedsores. Pore emphasized giving patients zinc supplementation. ↗
▶ Ep 1 · 25:21
clinical Gastroenterologists at University Hospitals refused to train surgeons in endoscopy, telling Ponsky 'we're not training any surgeons.' ↗
▶ Ep 1 · 25:47
clinical Ponsky trained in endoscopy with Jim King in Canton, Ohio, performing approximately 500 cases over 5-6 months during an extended elective. ↗
▶ Ep 1 · 26:57
clinical Early endoscopes were cleaned with green soap and stored in the back of cars, without high-level disinfection protocols. Operators did not wear gloves during procedures. ↗
▶ Ep 1 · 28:30
clinical When SAGES started, it had approximately 300 members. When Ponsky became president in 1990, the society was giving courses on surgical endoscopy and its relationship to surgical problem-solving. ↗
▶ Ep 1 · 28:48
clinical Jacques Perissat showed the video of laparoscopic cholecystectomy in the exhibit hall at the SAGES meeting in Louisville, Kentucky, marking a pivotal moment when Ponsky was SAGES president. ↗
▶ Ep 1 · 29:04
clinical When laparoscopic cholecystectomy was introduced, instruments could not be purchased and surgeons had to use gynecologic instruments initially. ↗
▶ Ep 1 · 29:10
clinical Ponsky took one of the first laparoscopic cholecystectomy courses taught by Nat Soper, George Bercy, John Hunter, and John Sackier in Salt Lake City. ↗
▶ Ep 1 · 29:27
clinical Ponsky's first two laparoscopic cholecystectomies at Mount Sinai were proctored by David Dupper, who had performed only 8 cases himself at that time. The first patient was a member of the hospital's board of trustees. ↗
▶ Ep 1 · 30:31
clinical Ponsky became director of surgical endoscopy at University Hospitals at age 29 as a new attending. ↗
▶ Ep 1 · 31:23
clinical The PEG (percutaneous endoscopic gastrostomy) was developed in May 1979 by Ponsky and pediatric gastroenterologist Mike Gower, with the first five cases performed on babies with birth asphyxia and psychomotor retardation. ↗
▶ Ep 1 · 31:31
clinical The PEG procedure was developed without IRB approval, only discussing the approach with patients' families. ↗
▶ Ep 1 · 31:50
clinical Ponsky became chief of surgery at Mount Sinai Hospital at age 32 in 1979. ↗
▶ Ep 1 · 32:54
clinical Mount Sinai Hospital had an animal laboratory that was larger than Cleveland Clinic's laboratory, providing Ponsky freedom to conduct courses and train fellows. ↗
▶ Ep 1 · 40:27
clinical The distal splenorenal shunt, once considered a great operation based on physiology to reduce variceal pressure without decreasing portal flow, became obsolete when endoscopic variceal banding was introduced. ↗
▶ Ep 1 · 41:05
clinical Ponsky performed 180 vertical banded gastroplasties in one year in the mid-1980s, an operation that later required reversal in many patients. ↗
▶ Ep 1 · 41:34
clinical Ponsky performed 1,600 colonoscopies in a single year during his practice. ↗
▶ Ep 1 · 43:09
clinical ERCP was developed primarily in Japan by Itaru Oi and colleagues, with contributions from German physicians and Peter Cotton's group in London. ↗
▶ Ep 1 · 43:40
clinical Ponsky learned ERCP primarily through watching videos and self-teaching, then traded training with George Brodmerkel in Pittsburgh—teaching him laparoscopy under local anesthesia in exchange for learning sphincterotomy. ↗
▶ Ep 1 · 48:24
clinical Early SAGES meetings focused on surgical problem-solving with endoscopy, addressing topics like managing bowel obstruction, evaluating suture lines, and treating intestinal volvulus endoscopically—distinct from ASGE's focus. ↗
▶ Ep 1 · 50:09
clinical Ponsky advocated to the Residency Review Committee (when Joe Fisher was head) for a minimum endoscopy requirement in general surgery training. The initial requirement of 50 cases was controversial but established endoscopy as a required component of general surgery. ↗
▶ Ep 1 · 51:55
quote Always volunteer, never say no, get involved in everything. And you know what, you'll find the time. You don't have to belabor decisions. Make a decision and move on. ↗

SAGES Stories: Dr. Jeffrey Ponsky on surgical endoscopy and the PEG tube legacy

▶ Ep 2 · 6:49
clinical Ponsky graduated Cleveland Heights High School with a 2.027 GPA and was advised by his counselor to consider trade school instead of college. ↗
▶ Ep 2 · 6:49
quote I was the worst damn student uh around. ↗
▶ Ep 2 · 7:03
quote I had a 2.027 with my with my acu graduating from high school ↗
▶ Ep 2 · 9:01
quote look, I'm gonna do this. As best I can do. I don't know what I'm gonna do. All I know is that I'm gonna work my butt off, and I'm not gonna screw around and I'm not gonna party cause I've done that my whole life and now I was just gonna study ↗
▶ Ep 2 · 9:44
quote I ate the book so I could spit it out ↗
▶ Ep 2 · 9:44
opinion Ponsky's transformation in college came from memorizing everything and studying constantly, discovering he had an 'unbelievable' memory that allowed him to 'eat the book and spit it out.' ↗
▶ Ep 2 · 10:05
quote I could eat the book and spit it out. ↗
▶ Ep 2 · 10:59
clinical Working as an orderly at Mount Sinai Hospital, Ponsky gave bed baths, changed bedpans, and cared for a high school classmate who became paraplegic after an auto accident, which deepened his commitment to medicine. ↗
▶ Ep 2 · 12:15
clinical Ponsky was promoted to scrub tech and surgeons allowed him to close fascia, despite the head nurse objecting that he wasn't permitted to do so. ↗
▶ Ep 2 · 12:43
clinical Ponsky never took calculus, using logarithms to work around it in physics, and the Case Western dean of admissions accepted him despite this after he stated he had already been admitted to two other medical schools. ↗
▶ Ep 2 · 14:14
clinical Ponsky chose Case Western Reserve (then Western Reserve) over Northwestern and Cincinnati primarily because his family lacked money and he needed to live at home rather than pay rent elsewhere. ↗
▶ Ep 2 · 19:43
opinion Bill Holden, chairman of surgery at Case, was an 'elegant' teacher who used the Socratic method and prioritized teaching over technical skill. ↗
▶ Ep 2 · 20:20
clinical Walter Parry taught using theatrical methods, including having students smell a room to perceive 'the smell of death' (though there was no actual smell) and performing bedside pinch grafts on bedsores at Metro Hospital. ↗
▶ Ep 2 · 20:54
quote that's the smell of death. ↗
▶ Ep 2 · 22:33
clinical Parry made Ponsky rewrite his first paper—a letter to the New England Journal about paradoxical air embolism—six times and read German poetry to him to encourage more poetic medical writing. ↗
▶ Ep 2 · 25:08
clinical When Ponsky requested an endoscopy elective as a resident, the head of GI at University Hospitals refused, stating 'we're not training any surgeons.' ↗
▶ Ep 2 · 25:47
clinical Charles Hube arranged for Ponsky to train with Jim King in Canton, Ohio, where Ponsky performed approximately 500 colonoscopy cases over 5-6 months using a mid-length scope not designed to reach the cecum. ↗
▶ Ep 2 · 26:19
clinical After returning from Canton, the head of gastroenterology told Ponsky 'you're not gonna touch this scope,' so he used the VA's Olympus colonoscope instead. ↗
▶ Ep 2 · 26:51
clinical Ponsky's mother-in-law purchased his first colonoscope after hearing at a family dinner that he couldn't get access to equipment; in that era, scopes were washed with green soap and stored in car trunks. ↗
▶ Ep 2 · 27:13
clinical As a senior resident, Ponsky performed emergency endoscopy cases day and night with Bob Zollinger Junior signing the paperwork, eventually doing all cases while GI physicians stopped performing them. ↗
▶ Ep 2 · 28:30
clinical When SAGES started, it had approximately 300 members; when Ponsky became president in 1990, the society was giving courses on surgical endoscopy and its relationship to surgical problem-solving. ↗
▶ Ep 2 · 28:48
clinical At the 1990 SAGES meeting in Louisville, Kentucky, Jacques Perissat showed video of laparoscopic cholecystectomy in the exhibit hall; Ponsky was SAGES president at the time and 'right in on the ground floor.' ↗
▶ Ep 2 · 29:06
clinical Early laparoscopic instruments were unavailable for purchase, so surgeons used gynecology instruments. Ponsky took one of the first training courses taught by Nat Soper, George Berci, John Hunter, and John Sackier in Salt Lake City. ↗
▶ Ep 2 · 29:27
clinical Ponsky's first two laparoscopic cholecystectomy cases at Mount Sinai were performed on a board of trustees member, proctored by David Dupper who had completed only eight cases himself. ↗
▶ Ep 2 · 31:11
clinical The PEG tube was invented in May 1979 when Ponsky and pediatric surgeon Michael Gower used transillumination (seeing light shine through the abdominal wall during endoscopy in neonates) to develop a minimally invasive gastrostomy technique, performing it on five babies with birth asphyxia and psychomotor retardation. ↗
▶ Ep 2 · 31:31
clinical The PEG tube procedure was performed without IRB approval; Ponsky and Gower only spoke with the patients' families before proceeding. ↗
▶ Ep 2 · 31:50
clinical Ponsky became chief of surgery at Mount Sinai Hospital at age 32, shortly after inventing the PEG tube. ↗
▶ Ep 2 · 32:44
opinion Mount Sinai was Ponsky's 'favorite place I ever worked in my life'—a small hospital where every staff member knew each other, with an animal research laboratory larger than Cleveland Clinic's. ↗
▶ Ep 2 · 32:44
quote the favorite place I ever worked in my life was Mount Sinai. ↗
▶ Ep 2 · 33:36
quote They were for-profit guys who could care less about quality. ↗
▶ Ep 2 · 33:36
opinion Ponsky left Mount Sinai in 1997 after 18 years when the hospital was sold to a for-profit company whose leadership 'could care less about quality.' ↗
▶ Ep 2 · 34:21
clinical Ponsky had all but one of his children before finishing residency; his last son was born during his final year of residency, and his daughter was born three years later after he joined Mount Sinai. ↗
▶ Ep 2 · 34:43
opinion Ponsky's wife had no partners helping her while he was on call every other night, but he credits his family—wife, children, and in-laws—as essential to his success, stating 'our success was a joint success, not just my success.' ↗
▶ Ep 2 · 34:49
quote You know, here's the important part. You, you gotta have a good partner. To have all the success doesn't come down cause you're a genius. You have to either destroy your family as many people did in the past, or use that to bolster your success ↗
▶ Ep 2 · 35:09
quote our success was a joint success, not just my success. ↗
▶ Ep 2 · 35:30
quote Who's watching our patients when we go? We all have a partner who's making rounds and taking our patients back when we have Complications ↗
▶ Ep 2 · 36:32
opinion Ponsky's greatest academic achievement was becoming chairman of the Department of Surgery at Case Western Reserve, though his parents were most proud of his role as chief of surgery at Mount Sinai because it was meaningful within the Jewish community they knew. ↗
▶ Ep 2 · 36:39
quote I think that, uh, I was chair of the board of the board of surgery. They wouldn't have understood that. That to them didn't mean anything. They saw it as the chief of surgery at Mount Sinai, that's enough. ↗
▶ Ep 2 · 38:47
opinion Ponsky has counseled fellows away from positions at his own institutions when he believed better opportunities existed elsewhere, considering factors like family proximity, academic opportunity, and institutional need rather than institutional prestige. ↗
▶ Ep 2 · 38:58
quote that is not the best opportunity for you. There is a great opportunity here because they need you more, because this is a better academic opportunity, because the people you'll be working with are more uh akin to what you need, or your family is in that city, your husband or wife's family is in that city. ↗
▶ Ep 2 · 39:32
quote go where the opportunities are best for your whole life, not just for your name of your institution. ↗
▶ Ep 2 · 40:27
clinical Ponsky performed distal splenorenal shunts early in his career at University Hospitals with Jerry Walkoff's assistance, believing the operation was 'the greatest thing since sliced bread' based on Dean Warren's physiologic approach, but the procedure became obsolete when endoscopic variceal banding was introduced. ↗
▶ Ep 2 · 40:27
quote I thought that a distal splenor renal shunt was a great operation when they first did it. I dare say you've not done those. ↗
▶ Ep 2 · 41:05
clinical Ponsky performed 180 vertical banded gastroplasty procedures in one year during the mid-1980s, believing it would be a great bariatric operation, but later surgeons had to reverse many of them. ↗
▶ Ep 2 · 41:34
opinion Ponsky performed 1600 colonoscopies in his final year of practice, predicting that in 20 years colonoscopy for screening may be obsolete. ↗
▶ Ep 2 · 41:34
quote I dare say in 20 years, you may say, I remember when we did colonoscopy for screening on all these patients ↗
▶ Ep 2 · 42:07
opinion ERCP is Ponsky's favorite procedure, which he describes as 'like golf for some people'—he would come in day or night to perform it and considers it a sophisticated procedure requiring 'body English.' ↗
▶ Ep 2 · 42:10
quote To me, ERCP is like golf for some people. I love ERCP. I would have come in day or night to do ERCP. I just loved it. ↗
▶ Ep 2 · 43:40
clinical Ponsky learned ERCP largely self-taught by watching videos, then arranged a teaching exchange with George Brodmerkel in Pittsburgh: Ponsky taught Brodmerkel laparoscopy under local anesthesia for liver biopsy, and Brodmerkel taught Ponsky sphincterotomy. ↗
▶ Ep 2 · 44:19
quote ERCP is like a a a a golf game. Is it body English in it. There it's very sophisticated and I love it. ↗
▶ Ep 2 · 44:54
opinion Ponsky obtained an executive MBA at the urging of hospital administrators who said he made decisions 'out of your gut' without understanding return on investment or financing; he describes the MBA as learning 'the language of business' and when to 'say bullshit at the right time' in business meetings. ↗
▶ Ep 2 · 45:36
quote I hate business. I don't care about business. ↗
▶ Ep 2 · 46:18
quote It's the people you meet. Yeah, it's the way they think. It's the way they approach a problem. ↗
▶ Ep 2 · 47:50
opinion Ponsky initially felt like a 'traitor' to ASGE when SAGES started because he was already on the ASGE governing board. ↗
▶ Ep 2 · 47:50
quote I felt a little bit like a traitor to ASGE because here are these group of surgeons who decided they're gonna start their own society. ↗
▶ Ep 2 · 48:24
opinion At early SAGES meetings, papers focused on surgical problem-solving with endoscopy (bowel obstruction evaluation, suture line assessment, volvulus management)—topics distinct from ASGE content—which convinced Ponsky of the society's unique value. ↗
▶ Ep 2 · 48:46
quote There is a reason for this society, intraoperative endoscopy, things that we would do. ↗
▶ Ep 2 · 50:02
quote Endoscopy has been made a part of surgery now and general surgery. It is a requirement for general surgery. ↗
▶ Ep 2 · 50:09
clinical Ponsky advocated to the Residency Review Committee (when Joe Fisher was head) for a minimum endoscopy case requirement in general surgery training; the 50-case requirement was initially controversial but established endoscopy as a core surgical competency. ↗
▶ Ep 2 · 50:45
quote The endoscope is now. The vehicle, it's the car that gets us to our destination. It drives us to our destination, then we put it down, we have it fixed, and we start to operate endoscopically ↗
▶ Ep 2 · 51:38
quote There's no reason that you can't be empathetic and be interested in psychiatric disease and still be somebody interested in the technical sides. ↗
▶ Ep 2 · 51:55
quote All I tell people is always volunteer, never say no, get involved in everything. And you know what, you'll find the time. ↗
▶ Ep 2 · 51:55
opinion Ponsky's philosophy is to 'always volunteer, never say no, get involved in everything'—he believes people will find the time, decisions don't need to be belabored, and residents can help with much of the work. ↗
▶ Ep 2 · 51:58
quote I think that surgeons can be better psychiatrists than some of the psychiatrists now. They're more empathetic in some ways ↗
▶ Ep 2 · 52:57
quote Don't be afraid to do everything. Don't say I'm too busy. You can do everything. ↗
▶ Ep 2 · 54:00
quote I don't take myself too seriously, and you shouldn't, because there are really other people around who've done many more things than me ↗
▶ Ep 2 · 55:18
quote if you don't have hobbies, you're cheating yourself. ↗
▶ Ep 2 · 55:24
clinical Ponsky's wife purchased him a Harley-Davidson trike (three-wheeled motorcycle) when he turned 70; she would not permit a two-wheel motorcycle. They have ridden to Sturgis, South Dakota. ↗
▶ Ep 2 · 56:04
quote The answer is no. I've never been tempted. Uh, to move because my family is here. It's all about your family. ↗
▶ Ep 2 · 56:12
clinical Ponsky lives on 8 acres with horses; his son Zach built a house on the adjacent 5-acre lot, his daughter bought a house two properties away with another 5 acres, son Todd lives within half a mile, and son Lee lives 'almost 2 miles' away—creating a family compound in Cleveland. ↗
▶ Ep 2 · 57:22
clinical Ponsky has a house in Florida and would travel there for long weekends during his working years, leaving Friday morning at 6 AM and returning Monday, using vacation days for Friday and Monday. ↗
▶ Ep 2 · 58:08
quote My family only wants to be near my wife. They can care less about me unless Jackie, unless something breaks. Then they call me, but they only want to be near my wife. ↗
▶ Ep 2 · 58:21
quote She's I'm gonna be very clear about that. She's pretty great, the glue that holds our family together ↗
▶ Ep 2 · 59:19
quote My favorite memories, my presidential addresses or highlights of my career. I love doing that. ↗
▶ Ep 2 · 59:45
quote We Are the Sages with the Japanese, because I go to tears when we do that every year, because that is not just a song, that is our soul, and that song says why we are different from all other societies, that says that we are a family. ↗

The invention of the PEG tube with Dr. Jeffrey Ponsky

▶ Ep 3 · 2:43
quote I was told I couldn't do it because I was a surgical resident, and that piqued my interest ↗
▶ Ep 3 · 3:02
quote I came back after that training and I was told I couldn't do endoscopy because I was a surgeon, couldn't touch the instruments ↗
▶ Ep 3 · 3:27
clinical In 1974-1975, there were no pediatric gastroenterologists, and Ponsky performed endoscopy on children, young adults, and neonates with GI problems using his personally owned scope. ↗
▶ Ep 3 · 4:33
clinical During neonatal endoscopy, the room would light up because babies were so thin; when pediatric surgeon Michael Gower pushed on the transilluminated light with his finger, an indentation was visible endoscopically. ↗
▶ Ep 3 · 4:42
quote Michael would push on the light with his finger, and I'd be scoping and I would see an indentation. And we realized we got together and said, you know, maybe we could do something with this. ↗
▶ Ep 3 · 4:59
clinical The first PEG tubes were constructed from OR gastrostomy tubes (small Pezzer catheters) with sutures threaded through the end and passed through an IV catheter (medicut) to create a dilator tip. ↗
▶ Ep 3 · 5:42
clinical The first five PEG procedures in May 1979 were performed in neonates with severe psychomotor retardation who were brain dead, fed by nasogastric tubes, had no chance of recovery, and were being sent for open gastrostomy before long-term nursing facility placement. ↗
▶ Ep 3 · 6:15
quote we have to do a major laparotomy on these babies, uh, but we have an idea for performing this, uh, by a new technique. Uh, we don't have any idea if it'll work. We think it will, it's pretty simple, but if it doesn't, we will do the laparotomy right there and then and complete the gastrostomy ↗
▶ Ep 3 · 6:25
clinical Informed consent for the first PEG cases consisted of telling mothers that if the new technique failed, immediate laparotomy and open gastrostomy would be performed. ↗
▶ Ep 3 · 6:37
quote That was the informed consent at that time. ↗
▶ Ep 3 · 6:42
clinical The first PEG procedures succeeded easily within a few minutes. ↗
▶ Ep 3 · 6:47
clinical After the initial five neonatal cases, Ponsky moved to Mount Sinai Medical Center and began performing PEG in adult stroke patients with similar neurologic prognosis who needed feeding access. ↗
▶ Ep 3 · 7:13
clinical Laboratory studies on PEG tract formation, tube dwell time before safe replacement, and leakage risk were conducted after clinical implementation—the reverse of typical research-then-clinical sequence. ↗
▶ Ep 3 · 7:28
clinical John Mellinger, who later worked at the American Board of Surgery, conducted original research on PEG tract formation. ↗
▶ Ep 3 · 7:44
quote it was sort of the reverse of what you would do now by going to the laboratory first and then And then to the operating room. ↗
▶ Ep 3 · 8:18
quote We didn't have IRBs in those days. ↗
▶ Ep 3 · 8:39
clinical Multiple medical device companies refused to manufacture the PEG tube initially, believing nobody would use it. ↗
▶ Ep 3 · 8:54
clinical A small company in Mentor, Ohio eventually manufactured the PEG tube exactly as designed by Ponsky and Gower. ↗
▶ Ep 3 · 9:06
quote we never even thought about patenting the tube. It wasn't even on our mind. ↗
▶ Ep 3 · 9:06
opinion Ponsky and Gower never patented the PEG tube; they were more interested in publication than patents and wanted to disseminate the technique. ↗
▶ Ep 3 · 9:18
quote We wanted to get papers out of it. We wanted to make a contribution to literature. We were more interested in publication than patents ↗
▶ Ep 3 · 9:39
clinical PEG tube complications included rare colonic perforation when the tube traversed the colon en route to the stomach, which still occurs rarely today. ↗
▶ Ep 3 · 9:51
clinical Exit-site infection was a major early PEG complication. ↗
▶ Ep 3 · 10:24
clinical PEG tubes evolved from multi-piece rubber construction to one-piece silicone, but have had very few modifications in the last few years and have become a commodity product purchased by hospitals at the lowest price. ↗
▶ Ep 3 · 10:50
clinical The PEG technique has remained very much the same as the original with only a few modifications. ↗
▶ Ep 3 · 11:19
clinical Ponsky and the manufacturing company conducted dozens of animal experiments to determine tube removal pressure, tip retention, and optimal tube size for FDA approval. ↗
▶ Ep 3 · 12:09
quote I said, wow, look at this. What else can we do with this thing? ↗
▶ Ep 3 · 12:13
quote the peg tube and was and still is the only time. Any instrument or needle was thrust through the abdominal wall into the GI tract. ↗
▶ Ep 3 · 12:13
clinical The PEG tube was the first and only time any instrument or needle was thrust through the abdominal wall into the GI tract and left in place. ↗
▶ Ep 3 · 12:55
clinical In 1975, Ponsky developed and published endoscopic tattooing using India ink injected alongside polypectomy sites to mark the location for potential surgical resection if cancer was found; the technique remains in use today. ↗
▶ Ep 3 · 13:38
quote there was a lot of low hanging fruit then we could do things that seemed logical, and that's the fun of a new area. ↗
▶ Ep 3 · 13:56
quote everybody thinks that everybody's been, everything's been discovered already, that's not true. ↗
▶ Ep 3 · 15:31
clinical In the late 1970s, surgical residents were on call every other night (36 hours on, 12 hours off) for five years of training. ↗
▶ Ep 3 · 15:49
quote I wanna have an elective that's a little bit easier. ↗
▶ Ep 3 · 15:58
quote I said, wow, that would be a great way to blow up 3 months. I won't have to take night off. This will be easier. That was an accident. ↗
▶ Ep 3 · 17:07
quote when you see a new technology, whatever that technology is. Investigate it, see if it's something that offers you something that you can uh make it your own and become an expert in it. ↗
▶ Ep 3 · 17:35
clinical In the mid-1970s, the predominant American endoscope was the ACMI (American Cystoscope Makers Incorporated) with a joystick control, approximately 1 cm diameter, with image quality like looking through ground glass. ↗
▶ Ep 3 · 18:00
quote it was like looking through ground glass. ↗
▶ Ep 3 · 18:03
clinical Japanese companies (Mashida and Olympus in the US) produced fiber-optic endoscopes with crystal-clear optics that were markedly superior to American models. ↗
▶ Ep 3 · 18:15
quote It was crystal clear. It was like you were just right there. ↗
▶ Ep 3 · 18:21
quote I bought the best instrument. ↗
▶ Ep 3 · 18:26
clinical 1970s fiber-optic endoscopes transmitted light via fiber bundles to the lumen and returned images to the eyepiece; photography required clipping a camera to the eyepiece for film-strip images. ↗
▶ Ep 3 · 18:51
clinical Teaching attachments for 1970s endoscopes consisted of a wire-connected second eyepiece that provided a dim image for trainees in darkened rooms. ↗
▶ Ep 3 · 19:06
clinical Around 1980, video chip technology placed a camera at the endoscope tip instead of using fiber-optic image transmission, displaying images on large monitors—the technology used in current endoscopes. ↗
▶ Ep 3 · 19:36
clinical In the late 1970s, neonates could tolerate endoscopes approximately 9 millimeters wide, which was the limit for safe use. ↗
▶ Ep 3 · 19:57
clinical The original PEG procedure was performed with an adult endoscope. ↗
▶ Ep 3 · 20:07
quote I would almost not let anyone touch it except me ↗
▶ Ep 3 · 20:56
clinical In the 1970s, endoscopes were cleaned between procedures using only green soap; high-level disinfection and sterilization protocols did not yet exist. ↗
▶ Ep 3 · 21:45
clinical The PEG tube received FDA 510(k) approval as a modification of existing gastrostomy tubes used for similar purposes, which is easier than approval for entirely novel devices. ↗
▶ Ep 3 · 22:17
clinical PEG indications expanded beyond feeding to include gastric decompression in gastroparesis or obstruction (including carcinomatosis), delivery of unpalatable feedings, and treatment of gastric volvulus. ↗
▶ Ep 3 · 23:00
clinical The PEG technique was adapted for colonic applications including sigmoid volvulus fixation and Ogilvie syndrome decompression, with multiple PEGs used for sigmoid volvulus. ↗
▶ Ep 3 · 23:30
quote I like to think that the endoscope is a tube, uh, it's a, it's a, a vehicle that gets us to where we need to be to perform an operation. That's what we think of as surgeons. ↗
▶ Ep 3 · 23:56
opinion Many endoscopic procedures developed by surgeons, including PEG, were extensions of surgical operations already performed via laparotomy. ↗
▶ Ep 3 · 25:32
clinical Gastroenterologists rapidly adopted PEG as a therapeutic procedure they could easily accomplish, driving widespread dissemination. ↗
▶ Ep 3 · 25:56
clinical Surgeons were slower to adopt PEG initially because they were not performing as much therapeutic endoscopy at that time, but they did not offer significant resistance. ↗
▶ Ep 3 · 26:40
clinical A properly performed PEG procedure takes under 5 minutes when done carefully by an experienced operator. ↗
▶ Ep 3 · 26:47
clinical Current PEG procedures still require patient sedation or anesthesia and constitute an intervention. ↗
▶ Ep 3 · 26:58
quote I want you to use your imagination that some day you will place a patient on a table. And have a machine that uses ultrasound or something, and has a gun that goes in and goes boom, and places that right into the stomach without anything, except maybe a little local ↗
▶ Ep 3 · 27:31
quote don't stop dreaming and stop thinking. ↗
▶ Ep 3 · 27:43
opinion Radiologists perform gastrostomy tube placement using ultrasound guidance, though Ponsky does not prefer the tubes they use. ↗
▶ Ep 3 · 32:57
quote you should always uh take a chance. Now, you shouldn't take a chance with patients' lives, but you should take a chance on developing new ideas and new procedures and new instruments. ↗

Summaries Jeffrey gave as host · 61 summaries

Recaps of other experts' statements, not Jeffrey's own clinical position.

Summaries Jeffrey gave as host · Acute Cholecystitis 6 summaries

Open the Acute Cholecystitis collection →

Gallstone Disease

▶ Ep 1 · 28:33
host summary Jeffrey Ponsky summarizing a resource: Some experts (George Bursey, Joe Peatland) advocate taking patients with persistent common duct stones directly to the operating room for intraoperative cholangiogram and transcystic or laparoscopic common duct exploration, with postoperative ERCP only if unsuccessful. ↗

Acute Cholecystitis

▶ Ep 2 · 4:21
host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed (usually by stone), causing backup of pressure in the gallbladder with decreased blood flow in the wall, and the wall can eventually rupture. ↗

Acute Cholecystitis

▶ Ep 6 · 4:21
host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: Acute cholecystitis is one of several obstructive diverticulopathies where a diverticulum (the gallbladder) off the biliary tree becomes obstructed (usually by a stone), causing pressure backup, decreased wall blood flow, wall thickening, and potential rupture. ↗
▶ Ep 6 · 18:53
host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder—not as close to the common duct as possible—to avoid bile duct injury. ↗
▶ Ep 6 · 27:09
host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: There is no magic number of trocars—additional ports should be placed wherever needed for adequate exposure and dissection. ↗

Acute Cholecystitis

▶ Ep 7 · 18:53
host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder—not as close to the common duct as possible, which is how you get in trouble. ↗
Summaries Jeffrey gave as host · Choledocholithiasis 4 summaries

Open the Choledocholithiasis collection →

Acute Cholecystitis

▶ Ep 1 · 4:21
host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed (usually by stone), causing backup of pressure in the gallbladder with decreased blood flow in the wall, and the wall can eventually rupture. ↗

Acute Cholecystitis

▶ Ep 7 · 4:21
host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: Acute cholecystitis is one of several obstructive diverticulopathies where a diverticulum (the gallbladder) off the biliary tree becomes obstructed (usually by a stone), causing pressure backup, decreased wall blood flow, wall thickening, and potential rupture. ↗
▶ Ep 7 · 18:53
host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder—not as close to the common duct as possible—to avoid bile duct injury. ↗
▶ Ep 7 · 27:09
host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: There is no magic number of trocars—additional ports should be placed wherever needed for adequate exposure and dissection. ↗
Summaries Jeffrey gave as host · Cholelithiasis 1 summary

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Acute Cholecystitis

▶ Ep 7 · 18:53
host summary Jeffrey Ponsky summarizes what Dr. John Rodriguez said: Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder—not as close to the common duct as possible, which is how you get in trouble. ↗
Summaries Jeffrey gave as host · Foundations of Minimally Invasive & Endoscopic Surgery 24 summaries

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SAGES Stories Episode 11 – Jeff Ponsky, MD

▶ Ep 3 · 8:20
host summary Jeffrey Ponsky summarizing a resource: I think you should consider just going to trade school because I don't think you're gonna do well in college and your parents don't have much money. ↗
▶ Ep 3 · 20:47
host summary Jeffrey Ponsky summarizing a resource: Don't you smell? Go back in and smell that. That's the smell of death. ↗
▶ Ep 3 · 25:29
host summary Jeffrey Ponsky summarizing a resource: We're not training any surgeons, just forget it. ↗
▶ Ep 3 · 26:19
host summary Jeffrey Ponsky summarizing a resource: You're not gonna touch this scope. ↗
▶ Ep 3 · 26:51
host summary Jeffrey Ponsky summarizing a resource: Go buy yourself a Hanukkah present. You got the scope. ↗
▶ Ep 3 · 45:22
host summary Jeffrey Ponsky summarizing a resource: You won't be a good businessman when you finish this, but you'll be able to sit in a business meeting and say bullshit at the right time. ↗

SAGES Stories: Dr. Jeffrey Ponsky on surgical endoscopy and the PEG tube legacy

▶ Ep 5 · 8:16
host summary Jeffrey Ponsky summarizing a resource: Jeff, I, I think you should consider, uh, just going to trade school because I don't think you're gonna do well in college and your parents don't have much money. ↗
▶ Ep 5 · 25:22
host summary Jeffrey Ponsky summarizing a resource: we're not training any surgeons ↗
▶ Ep 5 · 26:19
host summary Jeffrey Ponsky summarizing a resource: you're not gonna touch this scope. ↗
▶ Ep 5 · 26:51
host summary Jeffrey Ponsky summarizing a resource: go buy yourself a Hanukkah present. You got the scope. ↗
▶ Ep 5 · 45:22
host summary Jeffrey Ponsky summarizing a resource: the dean of the business school said the first day, he said, you won't be a good businessman when you finish this, but you'll be able to sit in a business meeting and say bullshit at the right time ↗

The invention of the PEG tube with Dr. Jeffrey Ponsky

▶ Ep 7 · 9:58
host summary Jeffrey Ponsky summarizing a resource: A Mayo Clinic study by Larson demonstrated that a single perioperative antibiotic dose almost eliminated PEG exit-site infections, establishing perioperative antibiotics as standard practice. ↗
▶ Ep 7 · 16:13
host summary Jeffrey Ponsky summarizing a resource: we're not gonna train a surgeon to do this. It's ours. ↗
▶ Ep 7 · 20:07
host summary Jeffrey Ponsky summarizing a resource: they would give me a nurse in the operating room, but they've had this guy, he's doing this wacko procedure. ↗
▶ Ep 7 · 24:45
host summary Jeffrey Ponsky summarizing a resource: At the 1980 Salt Lake City GI meeting with approximately 1500 attendees, a prominent Mass General surgeon stated he could perform open gastrostomy in 30 minutes and it was not a big deal. ↗
▶ Ep 7 · 25:00
host summary Jeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal. ↗
▶ Ep 7 · 25:24
host summary Jeffrey Ponsky summarizing a resource: At the same 1980 meeting, a world-renowned ERCP expert stated his only comment was 'I wish I had thought of it.' ↗
▶ Ep 7 · 25:27
host summary Jeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it. ↗

Jeffrey Ponsky: Portrait of a SAGES Pioneer

▶ Ep 18 · 5:11
host summary Jeffrey Ponsky summarizing a resource: You will not touch our instruments. We are not going to let a surgeon do endoscopy. ↗
▶ Ep 18 · 5:58
host summary Jeffrey Ponsky summarizing a resource: Go buy yourself a Christmas present, Hanukkah present. She said, go buy yourself a scope. We're buying it for you. ↗
▶ Ep 18 · 8:43
host summary Jeffrey Ponsky summarizing a resource: We're going to do a gastrostomy. We may have to open the baby, but we're going to try to poke a needle and just do it with the endoscope, and if it doesn't work, we'll just open. ↗
▶ Ep 18 · 9:14
host summary Jeffrey Ponsky summarizing a resource: Look, uh, it's a Jewish hospital. You're a Jewish guy and you're a good teacher. Go, go be the chairman over there. ↗
▶ Ep 18 · 17:36
host summary Jeffrey Ponsky summarizing a resource: We are the same. Like your brother. ↗
▶ Ep 18 · 35:28
host summary Jeffrey Ponsky summarizing a resource: When you run a department and you're a leader, you should protect your elders there, the elder staff, make sure they're protected and they're not threatened, but at the same time promote your younger staff. ↗
Summaries Jeffrey gave as host · Gastroparesis 7 summaries

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The invention of the PEG tube with Dr. Jeffrey Ponsky

▶ Ep 6 · 9:58
host summary Jeffrey Ponsky summarizing a resource: A Mayo Clinic study by Larson demonstrated that a single perioperative antibiotic dose almost eliminated PEG exit-site infections, establishing perioperative antibiotics as standard practice. ↗
▶ Ep 6 · 16:13
host summary Jeffrey Ponsky summarizing a resource: we're not gonna train a surgeon to do this. It's ours. ↗
▶ Ep 6 · 20:07
host summary Jeffrey Ponsky summarizing a resource: they would give me a nurse in the operating room, but they've had this guy, he's doing this wacko procedure. ↗
▶ Ep 6 · 24:45
host summary Jeffrey Ponsky summarizing a resource: At the 1980 Salt Lake City GI meeting with approximately 1500 attendees, a prominent Mass General surgeon stated he could perform open gastrostomy in 30 minutes and it was not a big deal. ↗
▶ Ep 6 · 25:00
host summary Jeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal. ↗
▶ Ep 6 · 25:24
host summary Jeffrey Ponsky summarizing a resource: At the same 1980 meeting, a world-renowned ERCP expert stated his only comment was 'I wish I had thought of it.' ↗
▶ Ep 6 · 25:27
host summary Jeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it. ↗
Summaries Jeffrey gave as host · Pancreatitis 1 summary

Open the Pancreatitis collection →

Gallstone Disease

▶ Ep 11 · 28:33
host summary Jeffrey Ponsky summarizing a resource: Some experts (George Bursey, Joe Peatland) advocate taking patients with persistent common duct stones directly to the operating room for intraoperative cholangiogram and transcystic or laparoscopic common duct exploration, with postoperative ERCP only if unsuccessful. ↗
Summaries Jeffrey gave as host · Psychomotor Retardation 18 summaries

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SAGES Stories Episode 11 – Jeff Ponsky, MD

▶ Ep 1 · 8:20
host summary Jeffrey Ponsky summarizing a resource: I think you should consider just going to trade school because I don't think you're gonna do well in college and your parents don't have much money. ↗
▶ Ep 1 · 20:47
host summary Jeffrey Ponsky summarizing a resource: Don't you smell? Go back in and smell that. That's the smell of death. ↗
▶ Ep 1 · 25:29
host summary Jeffrey Ponsky summarizing a resource: We're not training any surgeons, just forget it. ↗
▶ Ep 1 · 26:19
host summary Jeffrey Ponsky summarizing a resource: You're not gonna touch this scope. ↗
▶ Ep 1 · 26:51
host summary Jeffrey Ponsky summarizing a resource: Go buy yourself a Hanukkah present. You got the scope. ↗
▶ Ep 1 · 45:22
host summary Jeffrey Ponsky summarizing a resource: You won't be a good businessman when you finish this, but you'll be able to sit in a business meeting and say bullshit at the right time. ↗

SAGES Stories: Dr. Jeffrey Ponsky on surgical endoscopy and the PEG tube legacy

▶ Ep 2 · 8:16
host summary Jeffrey Ponsky summarizing a resource: Jeff, I, I think you should consider, uh, just going to trade school because I don't think you're gonna do well in college and your parents don't have much money. ↗
▶ Ep 2 · 25:22
host summary Jeffrey Ponsky summarizing a resource: we're not training any surgeons ↗
▶ Ep 2 · 26:19
host summary Jeffrey Ponsky summarizing a resource: you're not gonna touch this scope. ↗
▶ Ep 2 · 26:51
host summary Jeffrey Ponsky summarizing a resource: go buy yourself a Hanukkah present. You got the scope. ↗
▶ Ep 2 · 45:22
host summary Jeffrey Ponsky summarizing a resource: the dean of the business school said the first day, he said, you won't be a good businessman when you finish this, but you'll be able to sit in a business meeting and say bullshit at the right time ↗

The invention of the PEG tube with Dr. Jeffrey Ponsky

▶ Ep 3 · 9:58
host summary Jeffrey Ponsky summarizing a resource: A Mayo Clinic study by Larson demonstrated that a single perioperative antibiotic dose almost eliminated PEG exit-site infections, establishing perioperative antibiotics as standard practice. ↗
▶ Ep 3 · 16:13
host summary Jeffrey Ponsky summarizing a resource: we're not gonna train a surgeon to do this. It's ours. ↗
▶ Ep 3 · 20:07
host summary Jeffrey Ponsky summarizing a resource: they would give me a nurse in the operating room, but they've had this guy, he's doing this wacko procedure. ↗
▶ Ep 3 · 24:45
host summary Jeffrey Ponsky summarizing a resource: At the 1980 Salt Lake City GI meeting with approximately 1500 attendees, a prominent Mass General surgeon stated he could perform open gastrostomy in 30 minutes and it was not a big deal. ↗
▶ Ep 3 · 25:00
host summary Jeffrey Ponsky summarizing a resource: Jeff, I have to tell you this is a very cool technique. He said, but I can do a laparoscopic, I, I mean, it wasn't laparoscopic, and he said, I can do a laparotomy and a gastrostomy in a half an hour, and it's not a big deal. ↗
▶ Ep 3 · 25:24
host summary Jeffrey Ponsky summarizing a resource: At the same 1980 meeting, a world-renowned ERCP expert stated his only comment was 'I wish I had thought of it.' ↗
▶ Ep 3 · 25:27
host summary Jeffrey Ponsky summarizing a resource: I only have one thing to say to you. I wish I had thought of it. ↗